(All fields required)
Please enter a valid email.
Please enter your name.
What is : (So we know you are human.)
Please supply the correct answer.
When you come to the Emergency Department at Cincinnati Children’s, be sure to bring:
If you will be out of town, fill out this form, sign it and give it to the individual caring for your child. If your child requires a visit to our Emergency Department, tell the individual bringing your child to the Emergency Department to bring this form. (If there is a witness, the form does not need to be notarized. If there is no witness, the form will need to be notarized).
Did you forget your insurance card at your last visit? You may fill out this form and send it to our billing department within three days to prevent any delays.
Please do not allow your child to eat or drink anything before coming to the Emergency Department. Depending on the reason for the child’s visit, food or liquid could delay or prolong the visit.
3333 Burnet Avenue, Cincinnati, Ohio 45229-3026 | 1-513-636-4200 | 1-800-344-2462 | TTY:1-513-636-4900
New to Cincinnati Children’s or live outside of the Tristate area? 1-877-881-8479
© 1999-2015 Cincinnati Children's Hospital Medical Center