Patient Referral Form | Children's Healthcare of Atlanta

One of the largest multispecialty pediatric physician practices in the Southeast, with more than 500 physicians who are employed by Children's and/or serve as pediatric faculty members at Emory University School of Medicine.

Children's Physician Group Patient Family Request for Appointment - New Patients Only

This form is for Children’s Physician Group specialty appointments only, and is not used to make an appointment at one of our Urgent Care Centers.

Learn more about our Urgent Care Centers and how to reserve your spot online

If you are a current patient wanting a follow-up appointment for this specialty, call 404-785-KIDS (5437) to schedule an appointment.

Patient Information

Patient Name:

Patient Date of Birth: (mm/dd/yyyy)

Patient's Gender:

Male

Female

Parent/Guardian Name:

Home Address

Phone Number:

Alternate Number:

Email:

Preferred method of communication:

Phone

Patient's primary care doctor:

Specialty needed (Please select one):

If you chose other, please specify here:

Additional information (optional): Please provide further information about your child’s visit (i.e. reason for visit, symptoms, preferred doctor, preferred location, etc.).

* Required fields

Modal title

Children’s License Agreement

Children’s Physician Group

Children's Physician Group Patient Family Request for Appointment - New Patients Only