Secure Online Request

Request Health Information

 

 If you or the child about whom you have a question live in Arizona, you can also call us at

(602) 933-1400. Or you can submit your contact info using the form below, and we'll call you back!  

 

If you and the child about whom you have a question do not live in Arizona, visit the following directories:

Request for health information form

If this is an emergency, please call 911 or your local emergency services provider. For non-emergencies, please contact your healthcare provider. If you do not have a healthcare provider and live in the Phoenix metro area, please call our General Peds Clinic at (602) 933-0945.

The information you receive is not intended as a substitute for consulting with the child's healthcare provider. The Emily Center does not recommend or endorse any type of treatment.
 
Personal Information
First Name: *
Last Name: *
Address: *
 
City: *
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Zip: *
Phone (daytime): *
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Fax:
 
E-mail: *
Child's Information
Full Name:
Date of Birth:
Gender: *
Other Information
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Specific Questions: *