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First Name *

Last Name *

Patient Date of Birth *
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Patient Email *

Patient Phone *

*By clicking Reserve, I acknowledge that I have read and understand the Terms & Conditions. *

*By providing my mobile number, I hereby authorize Bethesda Medicine (including all associated medical practices) to contact me by mobile phone, including phone calls and texts. I understand that text messages are not sent in a secured (encrypted) format. Third parties may attempt to or actually access, use and disclose information transmitted by Geode Health to my cellular phone via text message. *

*I understand that emails are unencrypted and that there is some risk that information included in unencrypted messages, including email messages, may be intercepted or received by unintended third parties and/or stored or archived by our service providers and system operators. *

Do any of the following apply to you?

Anticipating treatment with controlled substances (e.g. stimulants such as Adderall, or benzodiazepines like Xanax, Klonopin etc) *

Seeking addiction treatment (e.g. Detox, Buprenorphine/Suboxone, Psychotherapy for addiction, etc.) *

In need of clinician to sign Disability, FMLA, or legal paperwork

Suicide attempt or active thoughts of self-harm in the last 2 weeks *