NEW PATIENT INTAKE FORM

NEW PATIENT INTAKE FORM

Are we a good fit?

Our physicians practice traditional medical care as outlined by the American Academy of Pediatrics (AAP). The office supports the vaccine schedule outlined by the Centers for Disease Control and the AAP which has been scientifically tested for safety and efficacy.

For our practice, there is no such thing as a tested or safe “alternative” vaccine schedule. We have a commitment to our patients to keep them safe and provide the best pediatric care available. This includes vaccinations on time, according to the CDC/AAP schedule.

The office accepts most commercial insurance plans. We do NOT accept MEDICAID insurances at this time.
How did you hear about us? *
Are you willing to vaccinate? *
Which physician would you like your child to see? *
Patient Information
Patient Name #1 *

First Name Middle Name Last Name
Male/Female
Date of Birth

Month Day Year
Date
Age *
Lives With:
Last well child visit: *

Month Day Year
If you are unsure about the DAY, type "01" for day.
Does your child have any ongoing medical problems (i.e.. breathing problems, heart problems, seizures, asthma, ADHD/ADD..ect )? IF NONE, PLEASE PUT NONE *
Patient Information

CHILD #2
Patient Name #2

First Name Middle Name Last Name
Male/Female
Date of Birth

Month Day Year
Date
Age
Lives With:
Last well child visit:

Month Day Year
If you are unsure about the DAY, type "01" for day.
Does your child have any ongoing medical problems (i.e.. breathing problems, heart problems, seizures, asthma, ADHD/ADD..ect )? IF NONE, PLEASE PUT NONE
Patient Information

CHILD #3
Patient Name #3

First Name Middle Name Last Name
Male/Female
Date of Birth

Month Day Year
Date
Age
Lives With:
Last well child visit:

Month Day Year
If you are unsure about the DAY, type "01" for day.
Does your child have any ongoing medical problems (i.e.. breathing problems, heart problems, seizures, asthma, ADHD/ADD..ect )? IF NONE, PLEASE PUT NONE
Patient Information

CHILD #4
Patient Name #4

First Name Middle Name Last Name
Male/Female
Date of Birth

Month Day Year
Date
Age
Lives With:
Last well child visit:

Month Day Year
If you are unsure about the DAY, type "01" for day.
Does your child have any ongoing medical problems (i.e.. breathing problems, heart problems, seizures, asthma, ADHD/ADD..ect )? IF NONE, PLEASE PUT NONE
Parent/Guardian Information
Parent/Guardian *

First Name Last Name
Phone Number *

Area Code Phone Number
Date of Birth *

Month Day Year
Date
Relationship to the patient:
Male/Female
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian Information
Parent/Guardian

First Name Last Name
Phone Number

Area Code Phone Number
Date of Birth

Month Day Year
Date
Relationship to the patient:
Male/Female
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary on Account
Please type the first and last name of parent who will be primary on the account (only one parent allowed as primary) *
Insurance
Primary Insurance Carrier: *
Subscriber Name *
Subscriber ID #: *
Subscriber DOB (Date of Birth): *
If you have any question please contact the New Patient Coorinator: Azalia Arrington (281)-499-6300 EXT 111
Should be Empty:

Patient Information

Patient Information

Patient Information

Patient Information

Parent/Guardian Information

Parent/Guardian Information

Primary on Account

Insurance