Miami Children's Hospital
Local: 305-666-6511
Toll Free: 800-432-6837
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Central Scheduling Appointment Form

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A dedicated central scheduling staff member will assist in scheduling the requested outpatient appointment. Once an appointment is scheduled you will receive appointment details via email, phone or fax within 24-48 hours (Monday through Friday).

Central scheduling hours of operations are Monday through Friday 8am to 6pm.

Phone: 305-663-8413

Fax: 305-662-8305



Fields marked with an * are required.

Upload Prescription (PDF, JPG, GIF or TIFF formats only):


Is this a new appointment? *



Procedure: *


Sedation: *



Additional Specifications:


Diagnosis: *


Patient Last Name: *


Patient First Name: *


Patient Date of Birth: *


Gender *



Ordering Dr. / Physician First Name: *


Ordering Dr. / Physician Last Name: *


Primary Care Physician First Name (If different from referring):


Primary Care Physician Last Name: *


Patient’s Address Street: *


Patient’s Address City: *


Patient’s Address State: *
 

Patient’s Address Zip Code: *


Patient’s Primary Phone: *


Patient’s Secondary Phone: *


Mother's Name:


Mother's Date of Birth:


Father's Name:


Father's Date of Birth:


Insurance Company: *


Insurance Phone Number:


Insurance Policy Number: *


Insurance Group Number: *


Subscriber Name:


Subscriber Date of Birth:


Preferred Appointment Date:


Preferred Appointment Time:


Form Completed by (Name): *


Email: *


Additional Comments:


Medical History

Is the patient any of the following?:
*






Allergies: *




Does the patient have any metals in the body: (For example: ear tubes, clips, shunts [programmable or non-programmable], ITB pump, PDA[metal in heart], pacemaker, Vagus Nerve Stimulator, braces/dental work) If yes please specify: *


Has the patient had any heart, brain or orthopedic surgeries? If yes please specify:


How much does the patient weigh?
(Use only numbers and specify in pounds)
*



Only for patients that are one year of age or younger:

Is the patient a premie?
*




History (Mark all of the following that apply) *














Person filling out this information *