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Wilmer Appointment Request

Wilmer Eye Institute Appointment Request Form

By taking a few minutes to complete this form, you—or your representative acting on your behalf—can request an appointment with a Hopkins specialist. To expedite your request, please provide as much information below as you can. Because we value your privacy, your personal information will not be used by us other than to schedule an appointment.

If this is an emergency, you may visit the Wilmer Eye Emergency Service, which is open 24 hours a day, 7 days a week at The Johns Hopkins Hospital.

Please note: Your information will be e-mailed to the Wilmer Referral Coordinator. E-mail sent over the Internet is not secure and this information may not remain confidential. You may make an appointment over the phone by calling us to ensure confidentiality.

Fields marked with « are required.

YOUR INFORMATION

(if requesting an appointment for someone else, otherwise skip this section)

Title

First Name

Middle Initial

Last Name

Relationship to Patient

Phone Number

(xxx-xxx-xxxx)

PATIENT INFORMATION

Patient's Title

Patient's First Name «

Patient's Middle Initial

Patient's Last Name «

Patient's Sex «

Date of Birth «

e.g., March 12, 1959 = 03/12/1959)

Address 1 «

Address 2

City «

State

Zip/Postal Code «

Country «

Primary E-mail Address «

Best time to call

Patient Phone Number «

(xxx-xxx-xxxx)

APPOINTMENT PREFERENCES

Earliest date «

Latest date «

What time of day would you prefer? «

Location

Where do you prefer to be treated?

PATIENT HISTORY

Were You Referred?

Yes No

Did a physician refer you to Hopkins?

Doctor's Name

Please tell us the name of the doctor or service where you were seen.

Diagnosis «

What is your diagnosis or complaint?

When did your symptoms begin?

Have you been a patient at Wilmer before?

Yes No

If so, when?

Treatment to Date

Please describe your treatment to date and your recommended next course of treatment

Are you seeking?

Other comments:

Please add any other information believe would be helpful.

PAYMENT INFORMATION

Health Insurance Plan «

Is this an HMO?

Yes No

Self-payment

Yes

I will be paying myself, via check or credit card.

Please note: before submitting this request by clicking on the Submit button below, please re-read your entries to check for accuracy.

Fields marked with « are required.

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