Get Tx Children's Hospital Appointment Request And Clinical Triage Form

Filling out the TX Children's Hospital Appointment Request and Clinical Triage Form online is a crucial step in scheduling a timely appointment for your child. This guide will provide you with clear, step-by-step instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to fill out the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date of your request at the top of the form. This helps track your appointment process.
3. In the 'Patient Information' section, provide the patient’s last name, first name, middle initial, and complete address including the street, city, state, and zip code.
4. Indicate if a translator is needed by checking 'Yes' or 'No,' and specify the language if applicable.
5. Fill in the parent or guardian’s name and contact numbers, including home, work, and cell phone.
6. Complete the 'Referring Physician Information' by providing the name of the referring physician, their practice, contact information, and office phone and fax numbers.
7. Address the referral issues in the designated questions section. Check all that apply and provide any necessary additional details, such as the reason for the referral and any previous test results.
8. In the 'Physical Exam' section, indicate whether the examination was normal and note any abnormalities if applicable.
9. Fill in the 'Family History' section, indicating any instances of sudden cardiac death, cardiomyopathy, or long QT syndrome.
10. List any prior tests performed, such as ECG, ECHO, CXR, or Holter, and include their results.
11. Complete the appointment details at the end of the form, specifying the appointment date, confirmation with the parent, time, clinic location, and cardiologist.
12. Once all sections are completed, review the form for accuracy, save your changes, and ensure you have the option to download, print, or share the form as needed.

Take action now and fill out the TX Children's Hospital Appointment Request and Clinical Triage Form online.