Aquatic Inquiry Form

Complete the form below to request an appointment.

Date
Has your child previously received care at any of St. Mary's Programs?*
- Yes
- No
Patient Full Name*
Patient First Name Patient Last Name
Date of Birth (MM/DD/YY)*
Gender*
- Male
- Female
Address*
Parent Information
Parent Full Name*
Parent First Name Parent Last Name
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?
- WED 3:45 PM
- WED 4:15 PM
- WED 4:45
- FRI 3:45 PM
- FRI 4:15 PM
- FRI 4:45 PM
How did you hear about us?*

Δ

Complete the form below to request an appointment.

Date
Has your child previously received care at any of St. Mary's Programs?*
- Yes
- No
Patient Full Name*
Patient First Name Patient Last Name
Date of Birth (MM/DD/YY)*
Gender*
- Male
- Female
Address*
Parent Information
Parent Full Name*
Parent First Name Parent Last Name
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?
- WED 3:45 PM
- WED 4:15 PM
- WED 4:45
- FRI 3:45 PM
- FRI 4:15 PM
- FRI 4:45 PM
How did you hear about us?*

Δ

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

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

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St. Mary's Home Care

333 Earle Ovington Blvd. Suite 600
Uniondale, NY 115533
Telephone: 718.281. 8600

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Telephone: (516) 621-2681

CMS Overall Rating: 5 | Health Inspection Rating: 5
Staffing Rating: 5 | QM Rating: 5

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Aquatic Inquiry Form

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