New Appointment Fax Form 9-2-10 - Children's Mercy Hospital - childrensmercy 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by selecting whether you are requesting a New Appointment or Medical Records. This is crucial for directing your request appropriately.
3. Fill in the Referring Physician's details, including their name, office fax number, contact name, and phone number. Ensure all information is printed legibly.
4. Enter the Patient's information: Name, Date of Birth (DOB), and gender. Follow this by providing the Parent or Guardian's name and contact details.
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. Detail the Reason for Referral/Symptoms clearly, including any relevant medical history such as lab results or radiology reports.
7. Select any location preferences for the appointment and circle relevant specialties that apply to your referral.
8. Complete any additional sections regarding outpatient procedures or specific conditions as required before submitting your form.

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