12.01.2013 Views

Nemours Children's Clinic, Philadelphia Patient Appointment Form

Nemours Children's Clinic, Philadelphia Patient Appointment Form

Nemours Children's Clinic, Philadelphia Patient Appointment Form

SHOW MORE
SHOW LESS

Create successful ePaper yourself

Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.

<strong>Nemours</strong> Children’s <strong>Clinic</strong>, <strong>Philadelphia</strong> <strong>Patient</strong> <strong>Appointment</strong> <strong>Form</strong><br />

OFFICE HOURS BOTH LOCATIONS: MONDAY-FRIDAY, 8:30 A.M. – 5:00 P.M.<br />

833 Chestnut Street, Suite 300 | <strong>Philadelphia</strong>, PA 19107<br />

Ph: 215-861-8830 | Fax: 215-861-8833<br />

Pediatric specialists listed below are available at the two <strong>Nemours</strong> Children’s <strong>Clinic</strong> offices on Chestnut Street in <strong>Philadelphia</strong>, PA.<br />

<strong>Appointment</strong> availability varies by specialist. All of <strong>Nemours</strong>/Alfred I. duPont Hospital for Children specialists are available in Wilmington, DE.<br />

<strong>Patient</strong>: _____________________________________________________________________________________<br />

Reason for Referral: (diagnosis code/comment)______________________________________________________________<br />

Referring Physician:_______________________________Physician’s Phone Number:___________________________<br />

Date:__________ Time: __________Specialist Name: __________________________________________________<br />

For appointments with specialists at 833 Chestnut Street, Suite 300: CALL 215-861-8830 For appointments with specialists<br />

Allergy & Immunology<br />

Stephen J. McGeady, MD<br />

Ejaz Yousef, MD<br />

Cardiology<br />

Paul C. Anisman, MD<br />

Bradley W. Robinson, MD<br />

Takeshi Tsuda, MD<br />

Endocrinology<br />

Gary Carpenter, MD<br />

Judith L. Ross, MD<br />

Martha Zeger Bardsley, MD<br />

Infectious Diseases<br />

Stephen Eppes, MD<br />

Abigail Freedman, MD<br />

Neurology<br />

Charles Brill, MD<br />

Christian Stanley, APN<br />

Neurosurgery<br />

Jeffrey W. Campbell, MD<br />

Pulmonology<br />

Robert Heinle, MD<br />

Rehabilitation Medicine<br />

Rochelle Haas, MD<br />

Surgery<br />

Barry Hicks, MD<br />

Urology<br />

T. Ernesto Figueroa, MD<br />

Susan Myers, APN<br />

Please arrive 15 minutes prior to your appointment to allow for registration. You are asked to bring any pertinent data such as medical records or X-ray films that may be helpful.<br />

Insurance information such as claim forms, insurance cards, co-pays, HMO referral forms, etc., must be presented at the time of registration.<br />

Directions to both <strong>Nemours</strong> Children’s <strong>Clinic</strong> locations on Chestnut Street<br />

Trouble finding us? Call 215-861-8830<br />

For more information:<br />

<strong>Nemours</strong>/Alfred I. duPont Hospital for Children, main number: 302-651-4000<br />

<strong>Nemours</strong>/Alfred I. duPont Hospital for Children, admissions: 302-651-4199<br />

<strong>Nemours</strong>.org<br />

__________________<br />

__________________<br />

__________________<br />

FROM POINTS NORTH AND WEST OF PHILADELPHIA:<br />

Take Exit 24 (Valley Forge) from Pennsylvania Turnpike. Take Route 76 East and follow signs for Exit 38 (I-676/US 30<br />

East, Central <strong>Philadelphia</strong>/Broad St.). Take Exit 38 to Vine St. and follow Vine St. to 8th St. Turn right onto 8th St. and<br />

continue to Market St. Cross over Market Street and the Central Parking System lot is on the right-hand side on Market<br />

St. between 8th and 9th Sts. When exiting the lot, walk out the 9th St. gate, turn left and walk towards Chestnut St.<br />

FROM DELAWARE, THE WALT WHITMAN BRIDGE AND POINTS SOUTH OF PHILADELPHIA:<br />

Take I-95 North, passing the Naval Base, stadiums, and Columbus Blvd. exits. Exit I-95 Northbound on the left hand<br />

side of the expressway at the I-676/Callowhill exit ramp (Exit #22). Stay in the middle lane on Callowhill St. and<br />

continue to 8th Street. Turn left on 8th St. and continue to Market St. Cross over Market St. and make a right turn into<br />

Central Parking System Lot. Central Parking System lot is between 8th and 9th Sts. on Market. When exiting the lot,<br />

walk out the 9th St. gate and turn left and walk towards Chestnut St.<br />

FROM THE BEN FRANKLIN BRIDGE:<br />

After crossing the bridge, stay in left lane. You will see a sign indicating 8th St. South, Chinatown. Make a left onto 8th<br />

St. and continue to Market St. Cross over Market Street and the Central Parking System lot is on the right-hand side on<br />

Market St. between 8th and 9th Sts. When exiting lot, walk out the 9th St. gate, turn left and walk towards Chestnut St.<br />

1015 Chestnut Street, Suite 601 | <strong>Philadelphia</strong>, PA 19107<br />

Phone: 215-861-9100 | Fax: 215-861-9090<br />

at 1015 Chestnut Street, Suite 601:<br />

CALL THE NUMBER LISTED BELOW<br />

Diagnostic Referral Service 215-861-9095<br />

Deborah Consolini, MD<br />

Jeffrey Malatack, MD<br />

Gastroenterology 215-861-9100<br />

Sheeja K. Abraham, MD<br />

Joan S. DiPalma, MD<br />

Neonatology 215-955-6974<br />

Shobhana A. Desai, MD<br />

Marcy B. Gringlas, MD<br />

1015 CHESTNUT 833 CHESTNUT<br />

5/10


Write down any questions you have about your child’s diagnosis. Items printed below may help you think of what you<br />

want to discuss during your visit with our <strong>Nemours</strong> team.<br />

My current concerns are:<br />

New medications for my child:<br />

My child has experienced these new symptoms:<br />

Are there other symptoms that I should be looking for?<br />

Please write down any additional questions you have for our <strong>Nemours</strong> team during your child’s visit.<br />

_______________________________________________________________________________________________________________________________________<br />

_______________________________________________________________________________________________________________________________________<br />

_______________________________________________________________________________________________________________________________________<br />

_______________________________________________________________________________________________________________________________________<br />

_______________________________________________________________________________________________________________________________________<br />

_______________________________________________________________________________________________________________________________________<br />

_______________________________________________________________________________________________________________________________________<br />

_______________________________________________________________________________________________________________________________________<br />

_______________________________________________________________________________________________________________________________________<br />

_______________________________________________________________________________________________________________________________________<br />

_______________________________________________________________________________________________________________________________________<br />

_______________________________________________________________________________________________________________________________________<br />

Advanced pediatric specialty care, here in your community.<br />

What is the next step in treating my child?<br />

What else can I do at home to help my child?<br />

Are there any activities or foods my child should avoid?<br />

Ask the name of the diagnosis/condition.<br />

Learn more at <strong>Nemours</strong>’ www.kidshealth.org. Information on our award-winning<br />

site is reviewed by our <strong>Nemours</strong> physicians specifically for parents, teens and kids.<br />

<strong>Nemours</strong> Children’s <strong>Clinic</strong>, <strong>Philadelphia</strong><br />

©2010. The <strong>Nemours</strong> Foundation. <strong>Nemours</strong> is a registered trademark of the <strong>Nemours</strong> Foundation.

Hooray! Your file is uploaded and ready to be published.

Saved successfully!

Ooh no, something went wrong!