Otolaryngology Head and Neck Surgery Request for Service 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name, referring provider's name, date of birth, practice name, and medical record number (if available) in the designated fields.
3. Fill in the date of request and parent’s name along with their phone number. Select a preferred time for contact from the options provided.
4. Indicate the patient's insurance type by checking the appropriate box. Remember to attach the patient’s demographics as required.
5. In Step 1, choose when you would like the patient to be seen by selecting one of the options: ASAP, within 2 weeks, or more than 2 weeks.
6. For Step 2, identify the chief complaint by checking all relevant issues listed. Be sure to provide additional details where necessary.
7. In Step 3, answer questions regarding how long the patient has had their condition and provide a brief patient history. Include any specific questions you want answered by the specialist.
8. Finally, ensure that all required documents such as current medications and pertinent labs are submitted along with this request before sending it to KidsDoc Fax #: 312.227.9832.

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