AIDHC_appt_pad._5.3.2010__navy_red:Layout 1 5/5/2010 3:34 PM Page 1 Nemours/Alfred I. duPont Hospital for Children PATIENT APPOINTMENT FORM 1600 Rockland Road Wilmington, DE 19803 | Hours: Monday-Friday 7:30 a.m. – 7:00 p.m. Appointment availability varies by specialist. Patient: __________________________________________________________________________________________________ Reason for Referral: (diagnosis code/comment)_______________________________________________________________________ Referring Physician:________________________________ Physician’s Phone Number:_______________________________________ Date An appointment has been scheduled for your child at the Nemours/Alfred I. duPont Hospital for Children on ____________________________ at ______________ in _______________________ with _________________________________________________________ Time Dept/Program Name, if applicable Call 1-800-416-4441 or visit Nemours.org/duponthospital and select ‘Make An Appointment’and your call will be returned within 48 hours. ____ Adolescent Medicine ____ Dialysis Unit ____ Muscles Disorders Program ____ Psychiatry ____ Allergy ____ Eating Disorder ____ Musculoskeletal Tumor Program ____ Psychology (Call 302-651-4560) ____ Apnea ____ Emergency Services ____ Neonatology ____ Pulmonary Function Lab ____ Attention Deficit & Hyperactivity Disorder ____ Endocrinology/Diabetes ____ Nephrology ____ Pulmonary Medicine ____ Enuresis Program ____ Neurofibromatosis Program ____ Rehabilitation ____ Feeding & Dysphagia ____ Neurology/Epilepsy Program ____ Rehabilitation Engineering ____ Gait Lab ____ Neurosurgery ____ Gastroenterology ____ Nutrition Services ____ General Pediatrics ____ Ophthalmology ____ Genetics ____ Orthopedics ____ Growth Discrepancy Program ____ Osteogenesis Imperfecta ____ Headache Program ____ Otolaryngology (ENT) ____ Hematology/Oncology ____ Outpatient Surgery ____ Infectious Disease/Lyme ____ Pathology ____Lab Work* ____ Physical/Occupational Therapy ____ Lymphedema ____ Plastic Surgery ____ Medical Imaging ____ Prosthetics ____ Audiology/Hearing Aids ____ Augmentative Communication ____ Behavior Consultation ____ Cardiology/Cardiothoracic Surgery ____ Cast Room ____ Cerebral Palsy ____ Children’s Advocacy Center ____ Cystic Fibrosis Program ____ Day Medicine ____ Dentistry (Call 302-651-5880) ____ Dermatology ____ Developmental Pediatrics ____ Diagnostic Clinic (seating & mobility) ____ Respiratory Care ____ Rheumatology ____ Speech Pathology ____ Spinal Dysfunction Program ____ Sports Medicine ____ Surgery ____ Urology ____ Weight Management ____ ________________________ ____ ________________________ ____ ________________________ 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. Insurance information such as claim forms, insurance cards, co-pays, HMO referral forms, etc., must be presented at the time of registration. * NEW SCHEDULING PROCEDURE FOR OUTPATIENT LAB The Outpatient Specimen Collection Area (OSCA) at AIDHC schedules routine blood collections and other lab work. Families should call Central Scheduling at 800-416-4441, M - F, 8:00 a.m. to 7:00 p.m. to schedule their child’s lab visit. Patients with a STAT lab request from their physician do not require an appointment. Appointment Scheduling: Admissions: Emergency: Main Hospital Number: 302-651-4200 or 800-416-4441 302-651-4199 302-651-4186 302-651-4000 AIDHC_appt_pad._5.3.2010__navy_red:Layout 1 5/5/2010 3:34 PM Page 2 Write down any questions you have about your child’s diagnosis. Items printed below may help you think of what you want to discuss during your visit with our Nemours team. My current concerns are: What is the next step in treating my child? New medications for my child: What else can I do at home to help my child? My child has experienced these new symptoms: Are there any activities or foods my child should avoid? Are there other symptoms that I should be looking for? Ask the name of the diagnosis/condition. Learn more at Nemours’ www.kidshealth.org. Information on our award-winning site is reviewed by our Nemours physicians specifically for parents, teens and kids. Please write down any additional questions you have for our Nemours team during your child’s visit. _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ DIRECTIONS TO THE HOSPITAL 1600 Rockland Road | Wilmington, DE 19803 From Rt 202 North: Take Route 202 South. Look for the AstraZeneca campus on the right. Make a right at the light onto Powder Mill Road (Route 141). Driving under a walkway overpass, stay on this road and it will become Children’s Drive and take you through the hospital gates. From North or South I-95: From I-95 North, take Exit 8 – Concord Pike/Route 202 N exit. Stay to the left. On Route 202, get in the far left lane. Turn left at the 3rd light onto Powder Mill Road (Route 141). Driving under a walkway overpass, stay on this road and it will become Children’s Drive and take you through the hospital gates. From the West: Take Route 141 North (Barley Mill Road), crossing the Tyler McConnell Bridge. Turn left at the duPont Experimental station, staying on Route 141 North (Powder Mill Road). Travel a mile and a half, making a right at the second light onto Children’s Drive. The hospital is straight ahead through the gates. To Rockland Center I, II, and Ronald McDonald House Follow the directions above. On Children’s Drive, facing the hospital’s stone gates, turn left onto Rockland Road. Rockland I is the first office building on your left. Rockland II is the second building on your left. A parking garage is located between I and II. The Ronald McDonald House is the large, yellow building past Rockland II. Your child. Our promise. Trouble finding us? Call 800-416-4441 Free parking and valet service are available around both the outpatient entrance (near playground) and visitor’s lobby (around the back of the hospital). ©2010. The Nemours Foundation. Nemours is a registered trademark of the Nemours Foundation.