Patient Appointment Form Specialty Care Center in Springfield Patient ________________________________________________________________________________________________ by somewhereinthemiddle

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									                                       Patient Appointment Form

                                             Specialty Care Center
                                                in Springfield
Patient: ________________________________________________________________________________________________

Reason for Referral: ______________________________________________________________________________________

Referring Physician: _________________________________________ Physician’s Phone: ______________________________

Practice Name: __________________________________________________________________________________________

Please arrive 15 minutes before your appointment to allow for registration. Bring along medical records or X-ray films that may
be helpful. Insurance information such as claim forms, insurance cards, HMO referral forms, etc., must be presented at time of
registration.

Pediatric Specialists at Springfield
Allergy                                          Endocrinology                                    Rehabilitation Services
215-590-2549                                     215-590-3174                                     215-590-5819
• Trong Le, M.D.                                 • David Langdon, M.D.                            • Occupational Therapy
                                                                                                  • Physical Therapy
Cardiology                                       Gastroenterology                                 • Speech (800-551-5480)
215-590-4040                                     • Janice Kelly, M.D. (610-524-9885)
• Richard Donner, M.D.                           • Edisio Semeao, M.D. (610-328-1600)             Ancillary Services
• Alexa Hogarty, M.D.                                                                             610-328-1600
• Susan Schachtner, M.D.                         Neurology                                        • Electrocardiograms
                                                 215-590-1719                                     • Electroencephalograms
Developmental Pediatrics                         • Daniel Licht, M.D.                             • Laboratory
877-827-2343                                     • Gihan Tennekoon, M.D.
• Marianne Glanzman, M.D.                        • Ernest Barbosa, M.D.
• Mary Pipan, M.D.
• Tahira Adelekan, M.D.




In order to ensure timely communication, please advise us if your primary care physician has recently changed his or her street address, phone
or fax number.


                       One Number, An Entire Network n 1-800 TRY CHOP n www.chop.edu
                                                             Specialty Care Center
                                                                in Springfield
                     Crozer-Keystone Healthplex • Pavilion II, Suite 221 • 100 West Sproul Road
                                      Springfield, PA 19064 • 610-328-1600



                                                                                                       From Exit 5 of I-476 (Blue Route)
    Chester County
                                                                                                       Head north on Route 1. Stay to the far right. Make a right
                                                                                                       onto Route 320 South. Take 320 South approximately
                                                                                                       1.2 miles. Go through four traffic lights. The fifth light
                                                                                                       is Country Club Drive. Make a right onto Country Club
                         Newtown
                          Square                                                                       Drive. The building and parking lot will be on your left.
                Delaware County
                                                             Springfield
                                                                            ore P
                                                                                  ike                  From the intersection of Route 3 and Springfield Road
                                                                     Baltim
                                                                                        Philadelphia   Turn onto Springfield Road, heading south. As you pass
                                               Sproul Road




                                  Media                                                                Cardinal O’Hara High School, stay to your right for
                                                                                                       Route 320 South (Sproul Road). Travel over the Route
                                                                                                       1 underpass. Continue on 320 South for approximately
              Pennsylvania                                                                             1.2 miles. Go through four traffic lights. The fifth light
                                     Chester
                                                                                                       is Country Club Drive. Make a right onto Country Club
                                                                                                       Drive. The building and parking lot will be on your left.
                                                                         New Jersey
      Delaware



From Exit 3 of I-476 (Blue Route)
Head east toward Swarthmore on Baltimore Pike. Go
through two traffic lights. At the third traffic light make
a left onto Route 320 North. At the second light on 320
make a left onto Country Club Drive. The building and
parking lot will be on your left.




                                                                                                                                                                    2691/50/09-08

								
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