Children's Healthcare of Atlanta Cardiology Appointment Request

Children's Healthcare of Atlanta Cardiology Appointment Request
Complete this form and a member of our scheduling team will contact you by 5 p.m. today. If this request is received after 3 p.m., we will call you the next business day. For urgent appointments, please call our office at 404-256-2593.

If this is an emergency, call 911.

This form is for appointments at Children's Cardiology locations. To make a primary care appointment at Hughes Spalding, please use this form.
Patient Information
Patient name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of insurance coverage*
Appointment information
Preferred day*

MondayTuesdayWednesdayThursdayFridayFirst available
Preferred time*

MorningAfternoon
Preferred Children's physician
Has the patient been seen at Children's Cardiology in the past?*
Preferred Children's location
Reason for appointment*
Referring physician or primary care physician*
Requestor information
I am submitting this appointment request for my*
Name*

First NameLast Name
Best contact number*
Please enter a valid phone number.
Email
example@example.com
Should be Empty:

Patient Information