Request Appointment Form – Children's Urology

Appointment Request Form

Notices
Please Read Carefully

The Children’s Urology Online Appointment Request Form is for non-emergencies and in-office appointments ONLY and NOT for surgical appointments. If you need to schedule a surgery appointment, please call please call (512) 538-2101 or send an email to surgery@childrensurology.com.

If you are having an emergency you need to call 911 or go to your nearest emergency room.

Please note, you will be contacted within 24-48 hours to confirm your appointment request.

Las formas de Children’s Urology para petición de citas. No son para citas de emergencias. Si tiene una emergencia debe llamar al 911 o vaya a la sala de emergencia más cercana. De lo contario, usted será contactado dentro de 24 horas para confirmar su petición de su cita.
New or Returning Patient
Please provide the appropriate information whether you are a new or returning patient.
Has your child ever been a patient at Children's Urology?*
Has your child been seen at Children's Urology within the past year?*
Patient Information
Patient's Name*
First Last
Patient's Date of Birth*
MM
DD
YYYY
Patient's Gender*
Parent or Policy Holder's Name*
First Last
Parent's Phone*
Parent's Email*
Enter Email Confirm Email
Preferred Contact Method*
Reason for Appointment
What is the patient being seen for?
Has the patient seen their primary care physician for this problem?
If you select yes, please provide Primary Care physician's name
Primary Care Physician's name:
Has the patient had any films or lab work performed?
If you select yes, please provide where and when the labs were done.
Where was imaging or lab work performed?
When was imaging or lab work performed?
Preferred Provider
We will try to accommodate all schedule requests to the best of our ability. We will contact you via email or phone to confirm your appointment. If you have any special requests regarding your appointment please let us know below.
Requested Provider
Returning patients and referrals may request a provider. If you would like to be seen as soon as possible select First Available. If you are requesting a follow-up appointment with a specific physician, the scheduling staff will look for the first open appointment.
Special instructions
Parent or Policy Holder Information
If the patient has never been seen at Children's Urology or they have not been seen in a long time, please fill out the information below as this will help speed up your check-in process.
Has the patient's (or parent's) address changed since your last visit?*
Policy Holder's (parent's) Name
First Last
Policy Holder's (Parent's) Date of Birth
MM
DD
YYYY
Policy Holder's (Parent's) Address
Street Address City State ZIP Code
Payment method*
Children's Urology requires all patients to complete a Financial Responsibility form. Patients without insurance must
Insurance Provider Information
Has the patient (or parent's) insurance information changed since your last visit?*
Which insurance provider do you have?
Please see our list of insurance providers for more information about insurance groups Children's Urology accepts.
If you chose Other, please state the name of your insurance provider
Insurance provider's phone number
Insurance Address
Street Address Address Line 2 City State ZIP Code
Group Number:
Insurance ID Number:
Medical Records Notice
Children's Urology can not see patient's without their referring provider's medical records on file in our office. Please ensure your doctor's office provides you or us with this information. Fax records to 512-472-2928
Please select an options for providing medical records:*
Confirm Request
Your request has not been competed yet. Please click the submit button to ensure that this process is complete. Please review that all information is complete and accurate
Please review all information and mark check box if you are ready to submit your request*
- I confirm that I have read the notices and hearby declare that the information provided is complete and accurate
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Mon–Thurs	8:00–5:00
Friday	8:00–4:30

Appointment Request Form

Notices

Please Read Carefully

New or Returning Patient

Patient Information

Reason for Appointment

Preferred Provider

Parent or Policy Holder Information

Insurance Provider Information

Medical Records Notice

Confirm Request