Sports Medicine Appointment Request | Children's of Alabama

In this section

Please fill out the required information for an appointment request. Your requested days and times will be taken into consideration and our scheduling team will contact you either by email or phone to confirm your appointment time. When requesting a time, please give our team 1-2 business days to respond to your request.

Which type of provider would you like to see?

If you would like, specify your preferred provider by name:

Patient First Name

Patient Last Name

Patient Date of Birth

Parent/Caregiver Name

Relationship to Patient

Address

Address 2

City/Town

State

ZIP/Postal Code

Country

Home Phone

Mobile Phone

Work Phone

Email Address

Preferred Contact

Type of Injury

Date of Injury

Type of Insurance (Blue Cross/Blue Shield, Tricare, etc)

Insurance Policy Number

Insurance Group Number

Policy Holder's Name

Policy Holder's Date of Birth

Patient's Relationship to Policy Holder

Preferred Days of the Week

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred Time of Day

7:30 - 8:30 am

8:30 - 9:30 am

9:30 - 10:30 am

12:45 - 1:30 pm

1:30 - 2:30 pm

2:30 - 3:30 pm

Have you seen another physician for this condition/injury?

Yes

No

If Yes, who?

Please Fax or email all records to 205-638-2879 or sportsmedicine@childrensal.org.

I agree to the Terms and Conditions.

Terms and Conditions

Users are advised that the information submitted through this form may be transmitted over unsecured email and releases Children's of Alabama and its employees, agents, and subcontractors from all responsibility or liability for any claims or damages arising from the content of the Email Form or the transmission thereof. By selecting the "I agree to Terms and Conditions" checkbox user acknowledges these terms and conditions and consents to transmission of the form.