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HomePrograms & ServicesAquatic Inquiry Form

Aquatic Inquiry Form

Date
Date Format: MM slash DD slash YYYY
Has your child previously received care at any of St. Mary's Programs?*
- Yes
- No
Patient Full Name*
First Last
Date of Birth (MM/DD/YY)*
Gener*
- Male
- Female
Address*
Parent Information
Parent Full Name*
First Last
Home Phone*
Cell Phone
Email*
Preferred Method of Communication*
- Home Phone
- Cell Phone
- Email
Insurance Information
Does the patient have insurance?*
- Yes
- No
Primary Insurance:
Secondary Insurance (if applicable):
Medical Information
Which of the following primary diagnoses applies to your child?*
- Torticollis
- Cerebral Palsy
- Neurological deficit
- Post-Surgical
- Orthopedic
- Spinal Cord Injury/Acute Flaccid Myelitis
How long has your child had this diagnosis?*
Please note a child is NOT a candidate if he/she has any of the following: Open wounds, Skin disorders/rashes, Tracheostomy/Vent, Central lines/PICC, Continuous Oxygen support.*
- My child does NOT have any of the above
Does child have any other medical condition/s? (Please list all)*
If your child is a candidate, what time of day would be best for you?
- Moring
- Afternoon
- Both
How did you hear about us?*

Contact Us

(718) 281-8800 | info@stmaryskids.org

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St. Mary’s Hospital for Children

29-01 216th Street
Bayside, NY 11360
Telephone: (718) 281-8800

St. Mary’s Preschool

Queens Borough President Helen Marshall
Early Education Center
Telephone: (718) 281-8848

Center for Pediatric Feeding Disorders

Telephone: (718) 281-8541

St. Mary’s Kids at Roslyn

1 Expressway Plaza, Suite 106
Roslyn Heights, NY 11577
Telephone: (516) 621-2681

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About
Programs & Services
For Families
- Get To Know Us
- Your Stay at St. Mary’s
Ways To Give
Why Give
Donate

Visitor Info
Contact & Locations
Careers
Events
News
Blog
English Link[glt language=”English” label=”English”]
Employee Covid-19 Screening
Search

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