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Patient Guide > Find A Physician > Online Appointment

To request an appointment, please fill out the form below. If you have any questions or would like to make an appointment by phone, please call the DOCS line at 202-877-DOCS.

In order for you to request an appointment electronically, you will need to provide confidential medical information. By proceeding through this notice and providing the requested demographic and medical information, you consent to the disclosure of such information to the relevant Washington Hospital Center clinical staff. The information that you provide will be placed into our electronic database. Your specific information will be accessed and used only for scheduling purposes. Aggregate data (without patient identifiers) may be analyzed at a later date. The information that you provide will not be shared with other organizations, and cookies or other tracers will not be used to collect information or track your computer use. However, you should note that electronic mail and other Internet communications channels may not be secure against interception by non-authorized individuals. If you do not wish to transmit your medical information electronically, you should call Washington Hospital Center at 202-877-DOCS to request an appointment.

Appointment For:
* Indicates required field
Patient's Name *
Address *
City *
State *
Zip *
Country
Date of Birth *
Gender * Male
Female
SSN
Health Insurance Provider(HIP) *
HIP Phone Number *
HIP Address
Insured's Name
Where to contact you:
Name(if different from patient name)
Email Address
Daytime Phone *
Evening Phone *
What is the best way for DOCSLine to contact you with information about your appointment?* Email
Daytime Phone
Evening Phone
Appointment Information:
Referring Physician(if applicable)
Physician Phone
Physician Address
Requested Physician
Have you seen this physician before? Yes
No
Have you been a Washington Hospital Center patient in the past? Yes
No
What type of illness do you have?
Please tell us about your medical condition and what type of appointment you are requesting. *
How did you hear about us? *
 
Please indicate when we can reach you during the day(all times are Eastern Standard Time(USA)) *

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Last updated: 06-26-2007

 

110 Irving Street, NW · Washington, DC 20010
Washington Hospital Center · (202) 877-7000