Intake Form - Childrens Hospital Los Angeles - chla 2026

1. Click ‘Get Form’ to open the Intake Form in the editor.
2. Begin by filling out the 'Patient Information' section. Enter your child's first, middle, and last name, date of birth, place of birth, gender, diagnosis, symptoms, and country of residence.
3. Next, complete the 'Family and Contact Information' section. Provide details for both parents including names, dates of birth, email addresses, telephone numbers, home addresses, countries of residence, and primary languages.
4. If applicable, fill in the 'Guardian/Other Contact' information with similar details as required for parents.
5. In the 'Clinical Information' section, enter your physician's name and contact details. Indicate whether clinical information is available.
6. Proceed to the 'Payment Information' section to specify how you will be paying for services.
7. Fill out the 'Travel Information' section with your planned timeframe for traveling to Los Angeles.
8. Finally, review the checklist at the end of the form to ensure all required documentation is prepared for submission.

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