New Appointment Fax Form 9-2-10 - Children's Mercy Hospital - childrensmercy 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by selecting 'New Appointment' at the top of the form. This indicates the purpose of your fax.
3. Fill in the referring physician's details, including name, office fax, contact name, and phone number. Ensure all information is printed legibly.
4. Enter patient information: name, date of birth (DOB), gender, and parent or guardian's name along with their contact numbers.
5. Indicate if a message can be left at the home/alternate phone and whether a translator is needed. Specify the language if applicable.
6. Provide detailed information regarding the reason for referral/symptoms and any relevant medical history such as lab or radiology results.
7. Select a location preference for the appointment from the options provided.
8. Circle any relevant specialties related to the referral to ensure proper routing of your request.
9. Finally, ensure that you have signed where indicated and attach any necessary insurance documents before sending.

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