To refer a patient to one of the Children’s Mercy Hospitals and Clinics (CMH) Specialty Clinics, please click on the New Patient Appointment Form below.
- Print this form and fax it with attachments, or submit it electronically and fax any attachments separately.
- Forms requiring a signature must be printed, signed, and faxed.
- Save or print a copy of this form before submitting it electronically.
Each patient is given a “next available” appointment slot. If the scheduled appointment is not soon enough, please
notify the Contact Center.
Please note that
Reader is required to view these forms.
* If you need to schedule two or more appointments on the same day for your patient, please contact the Physician Appointment Line in the Contact Center at (816) 234-3700 or (800) 800-7300 and ask for the “Provider Resource Nurse”.
The following clinics have additional information regarding the referral process and/or additional forms to be submitted with the appointment request or prior to the appointment.