Request a first-time appointment

Use the online form only if your child has never been seen or treated at Children's Memorial OR if you are requesting an appointment for a new specialty area. Do not use the online form to request return appointments.

A hospital staff member will call you about your request within three business days. If you do not receive a phone call at your preferred number, please call 1.800.KIDS DOC (1.800.543.7362).

* indicates required field

Appointment details

Specialist/Doctor	Preferred type of specialist if known Preferred physician's name
Location	Select preferred location Lake Forest Lincoln park Westchester Glenbrook Arlington Heights Tinley Park Winfield Preferred location *
Day and Time*	Select day of the week no preference Monday Tuesday Wednesday Thursday Friday Saturday Day of week a.m. p.m. no preference

Reason for appointment / Describe your concerns, if any* Did your primary care physician refer you to Children's Memorial?*

• Yes
• No, another physician referred me. Physician's name:
  Physician's phone number:
• I was not referred by a physician.

Child

Legal name	First* Last*
Home Address	Line 1* Line 2
City, State, Zip	City* Alabama Alaska APO Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida FPO Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State* Postal code*
Home phone*	(include area code)
Additional details	Birth date (MM/DD/YYYY)* Medical record# (if known)
	Gender* male female Has this child ever been seen at Children's Memorial Hospital before?* Yes No

Person requesting appointment

• Parent (or caregiver)
• Physician

Parent (or legal guardian information)

Name	First* Last*
	Address same as child's
Address	Line 1* Line 2
City, State, Zip	City* Alabama Alaska APO Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida FPO Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State* Postal code*
Phone & Email	Home phone w/area code* Business phone w/area code* E-mail*
	Which is the best number to contact you at during business hours? * Home Business

Contact preference

Occasionally we make our e-mail list available for mailings from Children's Memorial Hospital. If you prefer not to receive these, please check this box. Privacy policy .

Child's primary care physician

(the doctor you visit for immunizations, school physicals, etc.)

Name*	First Last
Address	Line 1* Line 2
City, State, Zip	City* Alabama Alaska APO Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida FPO Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State* Postal code*
Phone	(include area code)*

Insurance

Name & Type	Name of insurance* Select insurance type HMO PPO POS EPO none of these Insurance type*
	Does your insurance require a referral?* Yes No No, not needed