Frederick Health Appointment Request Form

1
Name:* This field is required.
First Name
Middle Name
Last Name
2
Address:* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Phone Number:* This field is required.
Area Code
Phone Number
4
Contact Information* This field is required.
PHONE NUMBER
Please Select
Please Select
Morning
Afternoon
Evening
BEST TIME TO CALL
EMAIL ADDRESS
5
Are you a new patient?* This field is required.
YESNO
6
Have you used our convenient Frederick Health Patient Portal to directly communicate with your provider? If not, it's quick & easy!

For more information and to login, please visit: FrederickHealth.org/Portal
7
Who would you like to schedule an appointment with?* This field is required.
Breast Surgery
Chest Surgery
Ear Nose & Throat (Otolaryngology)
Endocrine & Thyroid
Infectious Disease
Oncology & Hematology
Orthopedics & Sports Medicine
Pulmonary Medicine
Internal Medicine
Surgery
Sleep Medicine
Urology
8
Appointment Type:
Specialist Visit – New Appointment
Specialist Visit – Follow-Up Appointment
9
Primary Care Appointment Type:
I’d like to schedule my annual wellness visit/annual physical exam.
I have a specific concern or issue to discuss.
10
My preferred Primary Care location:
Frederick Health Crestwood
Frederick Health Emmitburg
Frederick Health Liberty
Frederick Health Rose Hill
Frederick Health Toll House
Frederick Health Urbana
Mt. Airy Health & Wellness Pavilion
No Preference
11
Provider Preference:
NAME
Please Select
Please Select
Male
Female
Does not matter
GENDER
LANGUAGE
12
What days work best for your appointment?* This field is required.Please check all that apply.
Monday
Tuesday
Wednesday
Thursday
Friday
13
What time works best for your appointment?* This field is required.Please check all that apply.
Morning
Afternoon
Evening
14
How did you hear about Frederick Health?* This field is required.Please check all that apply.
Existing Patient
Online (social media, website, search)
Mail
Radio
Newspaper
Magazine
Referral
Other
15
Please Note: This form is compliant with all HIPAA requirements. Your information will remain private and will only be used to provide you with healthcare service information, health and wellness education, and important health-related news and updates. Click here to read our full Notice of Privacy Practices.
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