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Request Appointment
To request an appointment with Dr. Josue, please fill out the following form. The office will be in touch regarding a free 15-minute consult.
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* Indicates required question
Name:
*
Your answer
Patient's Date of Birth
*
MM
/
DD
/
YYYY
Patient's Address
*
Your answer
Name of individual requesting treatment (if not patient):
Your answer
Relationship (self, spouse, parent, legal guardian, medical professional, other):
Your answer
Email address:
*
Your answer
Home/evening number:
*
Your answer
Patient gives permission to be called/have messages left at this number:
*
Yes
No
Required
Type of Insurance Coverage
*
Maryland Medicaid
CareFirst BlueCross BlueShield
Other
Self pay (Uninsured)
If the answer above is YES please submit the Following: Insurance Type | Policy Number or Member ID | Name of Registered Subscriber
*
Your answer
Chief complaint:
Your answer
Previous treatment (where, with whom, nature, outcome):
Your answer
List any medications you are currently taking (both psychiatric and non-psychiatric medications, including pain medications):
Your answer
List any recent hospitalizations (within the last month), including date of discharge:
Your answer
Where did you hear about the practice?
Your answer
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