Request an Appointment for a Medical Procedure Skip Navigation crm-header-2 | Nicklaus Children's Hospital

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Request an Appointment for a Medical Procedure

To request an appointment by phone please call (305) 663-8413 or toll free: (877) 624-8413 Monday – Friday, 7AM – 7PM.

Appointment Scheduling

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Preparer First Name: *

Preparer Last Name: *

Email Address: *

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Procedure Information

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Attach Documents *

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Is this a new appointment?: *

Procedure *

Preparer First Name:

Additional Specification/Comments:

Diagnosis *

Ordering Dr./Physician First and Last Name *

Name of Primary Care Physician:

(If different from referring)

Patient Information

Patient First and Last Name: *

Patient's Date of Birth (mm/dd/yyyy): * Month Day Year

Patient Gender: *

Patient Street Address: *

Patient Address City: *

Patient Address State/Region: *

U.S. ZIP Code: *

Home Phone: *

Mobile Phone: *

Parental Information

Parent 1 Full Name *

Parent 1 Date of Birth (mm/dd/yyyy): * Month Day Year

Parent 2 Full Name *

Parent 2 Date of Birth (mm/dd/yyyy): * Month Day Year

Insurance Information

Insurance Company: *

View the list of Insurance providers accepted by Nicklaus Children's Hospital.

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Group Number:

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Today

Do you have secondary insurance: Yes No

Secondary Insurance company

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Secondary Group Number

Secondary Policy Holder

Secondary Policy Holder DOB

Today

Medical History

Is the patient any of the following?:

Over 18 and cannot physically sign?:

Ward of the State

Non parental guardian

Allergies:

Iodine

Seafood

No Allergies

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

How much does the patient weigh?:

(Use only numbers and specify in pounds)

History (Mark all of the following that apply):

Achondroplasia

Dwarfism

Face/Neck Abnormalities

Fiber optic intubation

Heart problems

Lung problems (ex asthma)

Sleep Apnea

Congenital Disorders

None

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Request an Appointment for a Medical Procedure

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