Miami Children's Hospital

By completing this form, you can start the new patient appointment process. An International Referral Specialist will contact you directly to get additional information before confirming your first appointment.

Bold fields are required.


Information About the Patient
First Name
Last Name
Date of Birth	(mm/dd/yyyy)
Age
Gender	MaleFemale
Address
City
Country
Home Phone
Cell Phone
Fax
E-Mail
Diagnosis Information
Diagnosis Date	(mm/dd/yyyy)
Treatment Information
Is the patient currently under treatment?	YesNo
Treatment Information
Are you referring this patient to a specific Miami Children's Hosptial Physician?	YesNo
Physician's Name
Desired Appointment Dates
Information about your Primary Care Physician
First Name
Last Name
Address
City
Country
Office Phone
Office Fax
E-Mail
You will be contacted in order to review insurance coverage and obtain additional information. Medical and financial eligibility must be established prior to confirming an appointment. If you would like to leave a further message for the International Patient Services Office, please type it here.

All e-mail Referral Forms will receive a response within 24 hours, excluding weekends and holidays. The Miami Children's Hospital International Patient Services Office is open Monday through Friday from 8:30 a.m. to 5:00 p.m., Phone 305-662-8281.