Nicklaus Children's Hospital, formerly 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 *