Dr. Richards Consultation Appointments Inquiry

Consultation Appointments Inquiry

Please complete the following information
Before inquiring, please do not seek consultation if you are currently in a contested and complicated legal (or otherwise) arrangement with the child's other parent. My practice is currently unable to accept or manage these situations which would be better served within a larger system of care like Nationwide Children's.
Name of your child or adolescent

First NameMiddle InitialLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Sorry, Dr. Richards does not see children younger than 5, or older than age 17
Sorry, Dr. Richards only sees children and adolescent patients
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Name of person completing the form

First NameLast Name
Email (Email will be the method of contact)
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance
The above are the insurance panels Dr. Richards is contracted with through OhioHealth CIN. If you do not have one of these, you will be designated "self-pay"
Policy or ID Number
Group Number
Referral Source
Brief description of what brings you to seek consultation
Should be Empty: