Request Health Information

If you or the child about whom you have a question live in Arizona, please submit your request using our form below. You can also call us at (602) 546-1400.

If you and the child about whom you have a question do not live in Arizona, visit the following directories:

Medline Plus - directory for consumer health libraries
Eparent - information for parents of children with disabilities
Organized Wisdom - a portal to health information

Request for health information form

If this is an emergency, please call 911 or your local emergency services provider. For non-emergencies, please contact your healthcare provider. If you do not have a healthcare provider and live in the Phoenix metro area, please call our General Peds Clinic at (602) 546-0945.

The information you receive is not intended as a substitute for consulting with the child's healthcare provider. The Emily Center does not recommend or endorse any type of treatment. The information sent is designed to respond to your question or concern.

This is a secure form. Information is encrypted for complete security.

First name
Last name
Date of birth
Address line 1
Address line 2
City
State
Zip code
Home phone
Work phone
Cell phone
Fax
Pager
e-mail
Child's name
Child's date-of-birth
Child's sex
Number of siblings
Information request