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Appointment Form

Appointment Details

Scheduling with

Condition or visit reason

Disclaimer - Mnemonic
If you select a different condition, you will be required to choose a new location and a new date & time.
Input - Condition
Label
Please enter a valid condition.

Visit type

Disclaimer - Visit type
If you select a different visit type, you may be required to choose a new date & time.
Input - Visit type
Please select a valid visit type.

Location

Telehealth visit box title
Telehealth visit
Telehealth visit text box
Telehealth allows you to be seen via a computer or mobile device. You will be sent a link upon scheduling your appointment. You must physically be in the state of Maryland at the time of your telehealth visit.
Disclaimer - Location
If you select a different location, you may be required to choose a new date & time.

Day & time

Patient Information

Patient Visit Information

Reason for visit label
Reason for visit:
Input - Visit details
Label
200/200 Please enter valid additional details.

Insurance Information

Input - Insurance selection
Please select a valid insurance method.
Upload insurance card images * (Optional)
Input - Insurance card front image
Label
Placeholder
Front of insurance card
Input - Insurance card back image
Label
Placeholder
Back of insurance card
Please upload an image of the front and back of your insurance card.
Input - Insurance provider
Label
Please select a valid insurance provider.
Input - Insurance member ID
Label
Please enter a valid member ID.
Input - Insurance group number
Label
Please enter a valid group number.
Disclaimer - Insurance
If you choose not to upload or add insurance information, please bring a copy of your insurance card with you to the appointment.
Input - Submit
Some required fields have not been filled in. Please review each section carefully & fill in all required fields to continue.