Request an Appointment

To request an appointment, please complete all of the fields below and press Submit. If you need to request an application for dyslexia/learning disorders, please visit the Center for Dyslexia Application Process section of the Dyslexia page.

If you are a current Scottish Rite for Children patient with myChart access and have a question for your provider, please access your myChart patient portal account.

Note: If you are a referring health care professional, please complete the Referring Health Care Professional Request form.

Patient Details
Legal Sex
Current Patient
Parent/Guardian Information
Legal Sex
Who is your current Health Plan through?
I would like to receive email from Scottish Rite for Children about news, events and giving opportunities.

How did you find us?
Preferred Location and Reason for Visit
What is your preferred location?
Did an injury occur?