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Serving Maryland • Baltimore office • Telehealth for medication management & therapy • Call 472-248-6144 • Patient Portal

PATIENT INTAKE FORM

Welcome to Heart Own Medical Services

Thank you for choosing Heart Own Medical Services. To help our team prepare for your care, please complete the Patient Intake Form below with accurate and up-to-date information.

 

Your responses will help us better understand your needs and make the intake process as smooth as possible.

Please complete all required fields before submitting the form.

If you received this form after submitting a general or business inquiry, such as an inquiry from an insurance company, organization, vendor or other establishment, you may disregard this form.

We look forward to caring for you.

Patient Information

Date of Birth
Month
Day
Year
Preferred Contact Method

(Note: If you do not have your insurance card or know your member number, please provide your Social Security Number (SSN) instead so we can verify your coverage).

LOCATION

Visit us in Baltimore.

You’ll find Heart Own Medical Services in the Professional Johnston Building at Union Memorial Hospital.

3333 North Calvert Street, Suite 557
Baltimore, MD 21218

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Our office is wheelchair accessible. Please contact us before your visit if you have accessibility needs or questions about arriving at the building.

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Psychiatric medication management and therapy are available through telehealth for patients across Maryland. Spravato treatment, IV hydration and lab services require a visit to our Baltimore office.

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Phone: 472-248-6144
Fax: 472-248-6155
Email: admin@heartownmedical.com

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For general inquiries only. Please do not send sensitive health information by email.

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