Newborn –report & hospital visit request to Apple Pediatrics

 
Having a newborn is one of the most exciting moments in life.

If you child was just delivered or you are a medical provider who just delivered the child and you request that our pediatricians see the child at the hospital please submit the below form.

Please note that our pediatricians attend daily newborn nurseries at Mount Sinai, New York Presbyterian and Mount Sinai-West Hospitals. Once you submit the report they will be informed and will come and evaluate your child at your request. The visits occurs in the morning hours generally within 24 hours of the delivery.

  • If you are being discharged from the hospital and wish an office appointment for your newborn please make an Make an appointment for your child.
  • If you have additional medical concerns about your child and wish to consult the doctor electronically or need an urgent appointment which may not be available, please help our doctors appropriately triage your child’s situation by submitting a detailed consultation request at the e-consultation link.

Child’s first name (*) :

Child’s last name (*) :

Child’s DOB (*) :

Child’s time of Birth (*) :

The Medical Doctor who delivered the child (*) :

Parents’ first name (*) :

Parents’ last name (*) :

Parent’s email address (*) :

Parent’s phone number (*) :

The Hospital (*) :

The floor and unit where child is located (*) :

Please provide additional details of related to the child’s birth (such as type of delivery: vaginal, C-section; Apgar Score; concerns, complications or other important facts you wish the pediatricians to know):

I agree to the Authorization of Release of Medical Information, Payment, Terms and Conditions of my request; including authorization for payment of my credit card on file at Apple Pediatrics for the amount I selected above

Person Submitting the request: First Name (*) :

Person Submitting the request: Last name (*) :

Please sign your request (*) :

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