New Appointment Request Form - Seattle Children's
New Appointment Request Form
Pediatric Cardiology of Alaska
For urgent requests for appointment or to speak with our on call provider, call our office (907) 339-1945.
For clinical questions regarding referrals, please call our office and request to speak with the nurse.
Routine Urgent
|Date of referral: Best contact phone(s): |
|Patient last name: First: Middle: |
|Date of birth: |Sex: Male Female |
|Mother’s last name at birth: |Previous legal name: |
|Parent/guardian name: |Insurance Plan: ID #: |
|Primary caregiver’s email address: |Interpreter needed? Yes Language: |
|Preferred Clinic Location: |Services Requested: |
|If the preferred clinic is a location other than Anchorage, is it |Clinic visit with cardiologist |
|acceptable to wait until our next outreach clinic? Yes or No |OR |
|If no, we will schedule the appointment in Anchorage. |ECG only |
|Anchorage Ketchikan |Holter monitor only |
|Barrow Kodiak |Schedule future clinic visit with cardiologist if results abnormal |
|Bethel Nome | |
|Dillingham Sitka | |
|Fairbanks Soldotna | |
|Juneau Wasilla | |
|Clinical reason for this referral including relevant health history: |Referring Provider________________________ |
| | |
| |Phone Number:__________________________ |
| | |
| |Fax Number:____________________________ |
| | |
| |I am the Primary Care Provider |
| | |
| |Other_____________________________________ |
Please review the Clinic Referral Information at to help ensure timely and appropriate coordination of care. Federal guidelines require your request to clearly indicate if this is a consult versus a referral (transfer of care).
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Please fax this completed form, patient demographics, and last clinic note to (907) 339-1994 or email alaskacardiology@.
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