Center for Global HealthChildren's Hospital Los Angeles 2025

1. Click ‘Get Form’ to open the intake form in the editor.
2. Begin by filling out the 'Patient Information' section. Enter the patient's last name, first name, middle initial, date of birth, age, gender, place of birth, country of residence, country of citizenship, diagnosis, and symptoms.
3. Proceed to the 'Family and Contact Information' section. Fill in details for Parent #1 including their last name, first name, middle initial, date of birth, gender, relation to patient, phone number, email address, country of residence, primary language, employer's name and work address.
4. Repeat step 3 for Parent #2 and any other contacts if applicable.
5. Complete the 'Clinical Information' section by providing details about the referring physician and primary care physician.
6. Fill out the 'Residence Information' with both permanent and temporary addresses as needed.
7. In the 'Payment Information' section, indicate your payment method by checking the appropriate box.
8. Provide travel information in the designated section regarding your planned timeframe to visit Los Angeles.
9. Answer questions in the 'Additional Information' section regarding how you heard about us and your family's needs.
10. Finally, review the checklist at the end of the form to ensure all required documents are prepared for submission.

Start using our platform today to easily complete your intake form for Children’s Hospital Los Angeles!