Acquired Autonomic Dysfunction Program Patient Intake

After you fill out the form below, please submit the following information by email to or fax 215-590-4335.

  1. Download our New Patient Intake Form here. When it is completed, send it to 
  2. A medical summary or clinical summary from the referring primary care provider or specialist. If the referring provider is at CHOP, you do not need to provide this summary.
  3. A copy of the front and back of your insurance card (if new patient to CHOP).
  4. Medical records from outside institutions, including medical tests radiology reports and laboratory reports that pertain to the reason for your child’s visit can be faxed to 215-590-4335 or emailed to
  5. Download our HIPAA form here. When it is completed, send it to 

Please note that we will not be able to discuss scheduling any appointments until we receive all the information above.

Contact Information
Patient Information