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Request An Appointment | International Self-Pay Patients

Thank you for choosing Joslin Clinic for your care. To help us in planning your upcoming visit, please fill out the following questionnaire and submit it to the International Patient Coordinator.

Section 1: General Information

Is the patient currently (or has the patient ever been)a patient at the Joslin Clinic?

 Yes   No

Is this patient a United States citizen?

 Yes   No

Does the patient have health insurance?

 Yes   No


Please note: This form is only for self-pay international patients who do not have insurance. If you are a US citizen or have insurance, please schedule via the general scheduling line, 617-309-2440. Thank you.

Section 2: Patient Information

Title (Mr., Mrs., Ms., etc.):

Patient last name:

Patient first name:

Middle Name or Initial:

Date of birth (month/day/year):



Address and Contact Information



Postal Code:



Mobile Phone:

Local US Contact Phone:

Emergency Contact Phone:



 Required Field

Preferred contact method (phone, mobile phone, fax, or email?):

Patient's primary language:

Interpreter needed


 Yes   No

Please note:

If English is not your primary language, we strongly encourage use of a Joslin Diabetes Center interpreter. Joslin Diabetes Center provides free interpretive services to non-English speaking patients during their clinic appointments.

Section 3: Appointment Details

Patient's diagnosis/symptoms (please be specific):

Please describe your overall reason for visiting the Joslin Clinic:

Please list and explain expectations during your visit:

Appointment timeframe requested (Please plan on 5-8 business days to complete appointments):


Do you have a preference of a male or female doctor?

 Male  Female  No Preference

What type of diabetes does the patient have?

Does the patient wear an insulin pump (if applicable)?

 Yes   No

Appointment type requested:

 General Diabetes Examination

 Technology (Meter, Pump, Continuous Glucose Monitor)
 Education: Nutrition and meal planning
 Education: Exercise training
 Eye Services
 Geriatric Services
 Pharmacy Education
 Hypoglycemia (Diabetes related or non-diabetes)
 Behavioral Health

Other services, please list

Special laboratory testing requests

Please note:

In the process of scheduling an appointment, you may be asked to send a recent medical summary in English including diagnosis, pathology report and local physician's treatment plan. We will contact you regarding when and how to send this information. Please do not send X-ray films.

Any additional comments:

Please enter in the numbers shown in the image below into the blank box to proceed to the next page.

Page last updated: February 03, 2014