Medical Clinic Appointment Request Form
Please complete this form to request an appointment during our in-person medical clinic. Once you have completed this form we will match you with a doctor that best meets your needs. Filling out this form does not mean your appointment has been confirmed. 

Your appointment is confirmed  only  when you receive a confirmation email from telehealth@mapsredmond.org with a time and name of a healthcare provider. 

There will be a limited number of in-person appointments available on a first come, first-served basis. 

Note: The information collected in this form is privileged and confidential. All patient information is  protected by federal and state privacy laws. This information is received in trust, for the sole purpose of healthcare delivery. 
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Email *
First Name *
Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
City of Residence *
Gender   *
Reason for Appointment: please be as detailed as possible so we can make sure you receive the correct care. *
Preferred Appointment Time: please choose a 30 minute time slot between 10AM-1PM (if multiple times work for you, please select them and we will find a time that works best within that range). *
10 AM
10:30AM
11AM
11:30AM
12PM
12:30PM
1:00 PM
1:30 PM
Preferred Time
Do you have a preference for a male or female healthcare provider?  *
Preferred Language  *
Have you received the COVID-19 vaccine?  *
Have you ever had COVID-19? *
Do you have health insurance? Please note that insurance status does not impact your ability to receive health services with us. *
Current Medications: Please be sure to include ALL kinds of medications such as prescription medications, vitamins, herbal medication, and supplements.

If you do not take any medications, please write "None".
 *
Preferred Pharmacy: Please include name of the pharmacy and address. 

If you don't have a preference or need for medications, please write "None".
 *
How did you hear about the clinic?  *
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