Scottish Rite for Children

To request an appointment, please complete all of the fields below and press “Submit”.

If you are a current SRH patient with mySRH access and have a question for your provider, please access your mySRH Patient Portal account.

Note: If you are a referring provider, please complete the Referring Provider Request form.

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Question - Required - Preferred Location Dallas
Frisco
No Preference

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Question - Required - First Name

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Question - Required - Last Name

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Question - Required - Date of Birth

Month

Day

Year

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Question - Required - Current Patient

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Question - Required - Did an injury occur?

Question - Not Required - When did the injury occur or when did the symptoms begin?

Month

Day

Year

Details

Name:

First Required	Last Required

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Email: Required

Please check if you would like to receive periodic updates from Scottish Rite Hospital.

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Question - Required - Mobile Phone

Question - Not Required - Additional information regarding your visit

(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - How did you find us?

Question - Not Required - If Other, please indicate how.

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