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New Patient Appointment Request

 

If you would like to make an appointment and you have not been seen before, you may contact us via an online form to request your appointment. This service is for first-time patients only. Do not use this appointment form to make an appointment if you are a current patient. Call the office directly.

If you would prefer to make an appointment by telephone, call
 410-583-2726.
Staff is available Monday - Friday, 8:30 a.m. to 5:00 p.m.

Confidentiality Notice

The appointment request form requires you to answer confidential health information that is needed to complete your request and shall be utilized only for the purpose of helping you secure an office visit. Your information will be transmitted by e-mail and will not be secured by encryption software. By reading the Confidentiality Notice and providing the required health information, you consent to disclose confidential health information to Adult Attention Deficit Disorder of Maryland. You also acknowledge the risk of sending your information via e-mail and agree to not hold Adult Attention Deficit Disorder Center of Maryland or any of its affiliates, employees or agents liable for any damages you may incur as a result of the transmittal of your information.

 

New Patient Appointment Request Form

This information will allow us to contact you about scheduling your initial appointment.

This electronic request is not for established patients; instead please call the office directly for an appointment.

This electronic request is not for same day or next day appointments, nor for emergency appointments.

Billing

Treatment fee payment in full is requested at the time of the visit and remain the responsibility of the patient or assigned payor. Although we do not accept payments from any insurance, we will provide necessary forms to you so that you may submit directly to your insurance for reimbursement back to you. Please check with your insurance company for the out-of-network reimbursement to you.

Patient Information


First Name

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Last Name

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Best Time and Method To Contact You


Day of Week

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Time

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Contact Phone Number (*)

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Contact Email (*)

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Appointment Information


Preferred Day Of Week

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Preferred Time of Day

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