Schedule an appointment

There are many ways to schedule an appointment with Shriners Hospitals for Children – Cincinnati:

Complete and submit the online form below.
Call us toll-free at 855-206-2096.
Email us at helpachild@shrinenet.org
Download and print the form at the end of this page and mail it to the hospital.

Treatment Eligibility

Children up to age 18 are eligible for admission to Shriners Hospitals for Children if, in the opinion of our physicians, there is a reasonable possibility the child can benefit from the specialized services available.

Acceptance is based solely on a child’s medical needs. All care and services are provided regardless of a family’s ability to pay.

Please fill out the form below to schedule an appointment or download and fill out our PDF form below.

Child's Last Name
Child's First Name
Gender
- Male
- Female
Age
Date of Birth
Parent/Guardian Name
Parent/Guardian Address
Street Address Address Line 2 City State ZIP Code
Family Phone Number
Alternate Phone Number
Best time to call

: HH

MM
Reason for appointment (child's condition)
How did you hear about us?
Captcha
To be completed by Medical Personnel only
Provider Name
Facility/Provider Phone
Credentials
- MD
- DO
- PA
- RN
- CNP
- LPN
Facility/Provider Name
Street Address Address Line 2 City State ZIP Code

Open a PDF version of this form here.

Schedule an appointment

To be completed by Medical Personnel only

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