Online Remote Consultation Intake Form

Please fill out the form below to learn if your child is eligible for an online written consultation from a specialist at Children’s Hospital of Philadelphia. A member of our National Patient Services (NPS) team will reach out to you to learn more and determine next steps.

If you have any questions about the process or wish to speak to someone from our team about scheduling an in-person appointment at CHOP, please call us at 267-425-3560 Monday-Friday 8 a.m.-5 p.m. EST or email chopusa@chop.edu.

Service Area

Do you live within CHOP’s designated service area?

Pennsylvania: Berks, Bucks, Chester, Delaware, Lancaster, Lehigh, Montgomery, Northampton and Philadelphia counties
New Jersey: Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Hunterdon, Mercer, Middlesex, Monmouth, Ocean, Salem and Somerset counties
Delaware: New Castle CountyNew Castle County

Yes

You live within CHOP’s dedicated service area and do not qualify for a remote consultation. Please call 1-800-TRY-CHOP (1-800-879-2467) to schedule an in-person appointment or use this link.

Patient Information

Patient's First Name

Patient's Middle Name

Patient's Last Name

Patient's Date of Birth

Patient's City

Patient's State

Patient's County

Parent/Caregiver's First Name

Parent/Caregiver's Last Name

Parent/Caregiver's Relationship to Patient

Parent/Caregiver’s Email

Parent/Caregiver’s Phone Number

Additional Information

Please let us know the reason for your inquiry:

Please provide a brief description of the reason for your request and any additional details we should know about the patient.

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Online Remote Consultation Intake Form

Find a research study

Innovation and your child

Find research studies

Online Remote Consultation Intake Form

Online Remote Consultation Intake Form

Online Remote Consultation Form