Appointment Request Form - Lurie Children's Hospital Header Image

Appointment Scheduling and Request Form

Complete the form below to schedule or request an appointment.

IF YOUR CHILD IS HAVING AN EMERGENCY, CALL 911

In many cases, appointments can be scheduled online through MyChart for Lurie Children's. Patients who have had any care at Lurie Children's can now sign up for a MyChart account on their own at mychart.luriechildrens.org.
You can also click Next below to submit a request for an appointment and a hospital staff member will call you about your online request within one to three business days.

Appointment Request Form

In many cases, appointments can be scheduled online through MyChart for Lurie Children's. Please follow the activation instructions in the MyChart email you will receive to create an account within 1 business day of submitting this request, which will allow you to schedule an appointment on your own.
If you are unable to schedule an appointment through MyChart, a hospital staff member will call you about your online request within one to three business days.

Which specialty do you need to make an appointment for?*

What is the reason for your visit?*

Do you have a Lurie MyChart account for the patient you are trying to schedule for?*

Yes No

The specialty you have chosen allows for you to schedule an appointment on your own through MyChart! Please feel free to login into your MyChart account to schedule your appointment.

Your Name*

First Name

Initial (optional)

Last Name

Are you the parent or legal guardian?*

Parent Legal Guardian Power of Attorney Patient

No File Chosen

File uploads may not work on some mobile devices.

A copy of the legal paperwork verifying the authority of the patient’s personal representative (e.g., court appointed guardian documents, durable power of attorney for health care) must be accompany this form.*

Specialty Number

Patient Name*

First Name

Initial (optional)

Last Name

Patient Date of Birth*

Age Calculation Field in Days

12 years * 365 days per year = 4380 days. 17 years * 365 days per year = 6205

What language do you prefer for communication?*

English Spanish

Other:

Patient's Sex*

Female Male Unknown

Patient's Gender*

Female Male Other Something Else Transgender Female / Male-to-Female Transgenger Male / Female-to-Male Choose Not To Disclose

Patient's Primary Care Provider*

First Name

Last Name

Referring Provider (if different from the Primary Care Provider)

First Name

Last Name

Your Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Is the Address Above Also the Patient's Address?*

YES NO

Patient Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Your Phone*

Your Email

This is an optional field, but strongly recommended so that we may send you an activation code to set up a Lurie Children's MyChart Account. A MyChart account will allow you to schedule appointments online.

The specialty you have chosen allows for you to schedule an appointment on your own through MyChart! We will send you an activation email to create your own MyChart account within one business day.

If you are unable to schedule an appointment through MyChart on your own, a hospital staff member will call you about your online request within one to three business days.