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	-- Select from the following -- Mr. Ms. Mrs. Dr.
First Name
Middle Initial
Last Name
Relationship to Patient
Phone Number (xxx-xxx-xxxx)
PATIENT INFORMATION
Patient's Title	-- Select from the following -- Mr. Ms. Mrs. Dr.
Patient's First Name«
Patient's Middle Initial
Patient's Last Name«
Patient's Sex«	-- Select from the following -- Male Female
Date of Birth« e.g., March 12, 1959 = 03/12/1959)
Address 1«
Address 2
City«
State	-- Select from the following -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Africa Armed Forces Americas (except Canada) Armed Forces Canada Armed Forces Europe Armed Forces Middle East Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon
Zip/Postal Code«
Country«	-- Select from the following -- Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegowina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam 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 Crotia (local name: Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia, The Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Maurtania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svabard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic of Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe
Primary E-mail Address«
Best time to call	-- Select from the following -- Daytime Evening
Patient Phone Number« (xxx-xxx-xxxx)
APPOINTMENT PREFERENCES
Earliest date«
Latest date«
What time of day would you prefer?«	-- Select from the following -- Morning Afternoon Either
Location Where do you prefer to be treated?	-- Select from the following -- The Johns Hopkins Hospital Bayview Medical Center Columbia Frederick Green Spring Station I Green Spring Station II Odenton White Marsh Wyman Park Medical Center
PATIENT HISTORY
Were You Referred? Did a physician refer you to Hopkins?	Yes No
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?	-- Select from the following -- Treatment at Hopkins Second opinion
Other comments: Please add any other information believe would be helpful.
PAYMENT INFORMATION
Health Insurance Plan«
Is this an HMO?	Yes No
Self-payment I will be paying myself, via check or credit card.	Yes
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.