Texas Childrens Hospital (TCH) General Pediatrics Consult Service - texaschildrens 2025

1. Click ‘Get Form’ to open the Texas Children's Hospital General Pediatrics Consult Service form in the editor.
2. Begin by filling out the 'Patient Information' section. Enter the patient's last name, first name, age, and date of birth. Provide the home address, city/state, and ZIP code.
3. Indicate if this is a new patient to Texas Children’s by selecting 'YES' or 'NO'. If applicable, enter the TCH Medical Record Number.
4. Complete the insurance information by entering the primary medical insurance carrier and their telephone number. Specify if a physician referral authorization is required.
5. In the 'Parent/Guardian Information' section, fill in both parents' names and contact numbers. Indicate if an interpreter is needed.
6. Provide details for the referring physician including their name, email address, mailing address, office phone number, and fax number.
7. Lastly, describe the reason for referral along with any pertinent health information about the patient such as health problems and allergies.

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