Children's Mercy | Request Forms -

Request a call from the Nurse Advice Line

This form is not for emergency, urgent care, specialty follow up or well child visits

Please confirm the following:

This is not regarding an emergency room, urgent care or inpatient visits within the past 48 hours
AND

My child is not followed in a specialty clinic at Children's Mercy

If your child was seen at a CM ED, UC, or was recently discharged from CM within the past 48 hours, please call 816-234-3000.

To schedule an appointment in one of our Specialty clinics, please call 816-234-3700.

To schedule a well child visit in our Primary Care Clinic, please call 816-234-3000.

If your child is ill and you would like to speak with a nurse or schedule an ill visit in our primary care clinic, please complete the following and a nurse will call you back

Parent/Guarantor Information

Parent/Guardian First Name *

Parent/Guardian Last Name *

Primary Phone Number *

Secondary Phone Number

Language *

Child Information *

Child First Name

Child Last Name

Date of Birth

Sex

Child First Name

Child Last Name

Date of Birth

Sex

Child First Name

Child Last Name

Date of Birth

Sex

Child First Name

Child Last Name

Date of Birth

Sex

Child First Name

Child Last Name

Date of Birth

Sex

Child First Name

Child Last Name

Date of Birth

Sex

Provider Information *

Primary Care Provider Name

Name of Practice/Office

Additional Information *

Has your child ever been seen at a Children's Mercy hospital or clinic?

Yes

What questions do you have for the nurse?

Leave this field blank

Request a call from the Nurse Advice Line

This form is not for emergency, urgent care, specialty follow up or well child visits

Please confirm the following:

Parent/Guarantor Information

Child Information *

Provider Information *

Additional Information *

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