Metro Direct Care Medical Patient Portal

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Available Forms

1. Patient Demographics 2. Patient Insurance Information 3. Health History 4.Medicinal Marijuana Screening Questionaire

1. Patient Demographics

Please call 202-368-6820 prior to submitting forms so we can make sure you are in our coverage area. All questions contained in this questionnaire are strictly confidential and will become part of your medical record. A typical phone, text or video consultation starts at $60.00. If after this consultation a house call visit is needed, we will credit your consultation fee to the house call visit. If the patient has a Primary Caretaker, please be considerate of the patient and doctors time. Only the primary caretaker or 1 designated person should be in the room with the patient and doctor.

Patient Information

New Patient? *

Yes

First Name *

Middle Name

Last Name *

Date of Birth *

Gender *

Male

Female

Social Security Number *

Medicare ID Number

Marital Status

Single

Married

Partnered

Other

Street Address (Line1) *

Street Address (Line2)

City *

State *

Zip-code *

Phone *

At least one phone number is required.

Cell Phone

Work Phone

Email Address

Required for Portal communications

Preferred Method of Contact *

Home Phone

Cell Phone

Work Phone

Check all that apply

May we leave a message? *

Yes

Emergency Contact

Emergency Contact Phone Number

Emergency Contact Address

Relationship

Parent

Spouse

Partner

Sibling

Child

Friend

Other

Primary Guardian

Name, Address and Phone

Preferred Pharmacy

Name, Address and Phone

Primary Care Physician

Name, Address and Phone Number

Method of Payment *

Cash

Check

VISA

AMEX

Other

Credit Card Number

Please make sure all information is exactly as information on Credit Card as the visit will be charged to your card prior to doctors arrival. We do not accept Debit Cards for prepayment.

Expiration

CCV

Billing Zip Code

Billing Address

If different from patient.

Name on Credit Card

If different from patient.

How did you hear about us? *

Internet

Google

Yelp

Friend

Leisure World News

Beacon Newspaper

Other.. Please list under notes

By replying you help keep advertising costs down. Thank you.

Search Phrase Used?

Notes

* Required field