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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)
(xxx-xxx-xxxx)
PATIENT INFORMATION
e.g., March 12, 1959 = 03/12/1959)
(xxx-xxx-xxxx)
APPOINTMENT PREFERENCES
Where do you prefer to be treated?
PATIENT HISTORY
Were You Referred?
Did a physician refer you to Hopkins?
Please tell us the name of the doctor or service where you were seen.
What is your diagnosis or complaint?
Have you been a patient at Wilmer before?
Please describe your treatment to date and your recommended next course of treatment
Please add any other information believe would be helpful.
PAYMENT INFORMATION
Is this an HMO?
Self-payment
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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