New patient

New Patient Intake

In-clinic in Silver Spring · Telehealth statewide across Maryland, including Saturday and Sunday appointments.

Please bring your insurance card and driver's license to your first visit — we do not collect document photos online.

Full legal name*

Date of birth*

Phone*

Email*

Home address

Street address*

City*

State*

ZIP*

Height (e.g., 5'8")*

Weight (e.g., 210 lb)*

Marital status

Number of children

Smoker

Preferred pharmacy

Pharmacy name

Edit this if you prefer a different pharmacy.

Pharmacy address

How would you like to pay?

Insurance — we'll verify your benefits before your first visitSelf-pay clinic fee $150/month

Insurance carrier

Member ID

HIPAA notice

The health information you provide here is protected health information handled under HIPAA and stored securely. Your information is used only to schedule and verify coverage. We never sell your information, and we never display your date of birth, member ID, or medical history back to you on screen.

I confirm this information is accurate and consent to be contacted by First Response Doctors Clinic to schedule care and verify coverage.

Prefer to talk? Call 240-604-2949

Your clinician sets your goals — many plans target 10–16 lbs/month with strict protein protocols; individual results vary. Medication and dosing are always determined by your clinician after evaluation.

Questions? Call 240-604-2949