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:

I am not calling about an emergency room, urgent care or inpatient visit 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 Children's Mercy emergency room or urgent care or was discharged from Children's Mercy 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 this form. 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?

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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