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 and Texas Children's (CHIP). 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?*
How many kids are in the family?*

Patient Information
Patient Name #1*

First NameMiddle NameLast Name
Male/Female
Date of Birth*

MonthDayYear
Date
Age*
Lives With:*
Last well child visit:*
Does your child have any ongoing medical problems (i.e.. breathing problems, heart problems, seizures, asthma, ADHD/ADD..etc)? IF NONE, PLEASE TYPE NONE*

Parent/Guardian Information
Parent/Guardian*

First NameLast Name
Phone Number*
Date of Birth*

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

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Information
Parent/Guardian*

First NameLast Name
Phone Number*
Date of Birth*

MonthDayYear
Date
Relationship to the patient:*
Male/Female*
Email*
example@example.com
Is your home address the same?

Yes
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact on the family's Account*
Please type the first and last name of parent who will be primary on the account (only one parent is allowed as primary)
Insurance
Primary Insurance Carrier:*
Subscriber Name*
Subscriber ID #:*
Health Insurance Card : *

Browse Files
Upload the Front & Back Cancelof
Uninsured

Yes
Release of Medical Records
Medical Records Release : *

Browse Files
If you have your child's medical records, you may upload them here. If you don't, please click the link listed below, save and upload. Cancelof
https://www.pediatricsaroundthebend.com/_files/ugd/71a7cb_a27970887d014385abd5539dc0edee29.pdf

If you have any question please contact the office at (281)-499-6300

Patient Information
Patient Name #1*

First NameMiddle NameLast Name
Male/Female*
Date of Birth*

MonthDayYear
Date
Age*
Lives With:*
Last well child visit:*
Does your child have any ongoing medical problems (i.e.. breathing problems, heart problems, seizures, asthma, ADHD/ADD..etc)? IF NONE, PLEASE TYPE NONE*
Patient Information

CHILD #2
Patient Name #2*

First NameMiddle NameLast Name
Male/Female*
Date of Birth*

MonthDayYear
Date
Age*
Lives With:*
Last well child visit:*
Does your child have any ongoing medical problems (i.e.. breathing problems, heart problems, seizures, asthma, ADHD/ADD..etc)? IF NONE, PLEASE TYPE NONE*

Parent/Guardian Information
Parent/Guardian*

First NameLast Name
Phone Number*
Date of Birth*

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

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Information
Parent/Guardian*

First NameLast Name
Phone Number*
Date of Birth*

MonthDayYear
Date
Relationship to the patient:*
Male/Female*
Email*
example@example.com
Is your home address the same?

Yes
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact on the family's Account*
Please type the first and last name of parent who will be primary on the account (only one parent is allowed as primary)
Insurance
Primary Insurance Carrier:*
Subscriber Name*
Subscriber ID #:*
Health Insurance Card : *

Browse Files
Upload the Front & Back Cancelof
Uninsured

Yes
Release of Medical Records
Medical Records Release : *

Browse Files
If you have your child's medical records, you may upload them here. If you don't, please click the link listed below, save and upload. Cancelof
https://www.pediatricsaroundthebend.com/_files/ugd/71a7cb_a27970887d014385abd5539dc0edee29.pdf

If you have any question please contact the office at (281)-499-6300

Patient Information
Patient Name #1*

First NameMiddle NameLast Name
Male/Female*
Date of Birth*

MonthDayYear
Date
Age
Lives With:*
Last well child visit:*
Does your child have any ongoing medical problems (i.e.. breathing problems, heart problems, seizures, asthma, ADHD/ADD..etc)? IF NONE, PLEASE TYPE NONE*
Patient Information

CHILD #2
Patient Name #2*

First NameMiddle NameLast Name
Male/Female*
Date of Birth*

MonthDayYear
Date
Age
Lives With:*
Last well child visit:*
Does your child have any ongoing medical problems (i.e.. breathing problems, heart problems, seizures, asthma, ADHD/ADD..etc)? IF NONE, PLEASE TYPE NONE*
Patient Information

CHILD #3
Patient Name #3*

First NameMiddle NameLast Name
Male/Female*
Date of Birth*

MonthDayYear
Date
Age
Lives With:*
Last well child visit:*
Does your child have any ongoing medical problems (i.e.. breathing problems, heart problems, seizures, asthma, ADHD/ADD..etc)? IF NONE, PLEASE TYPE NONE*

Parent/Guardian Information
Parent/Guardian*

First NameLast Name
Phone Number*
Date of Birth*

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

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Information
Parent/Guardian*

First NameLast Name
Phone Number*
Date of Birth*

MonthDayYear
Date
Relationship to the patient:*
Male/Female*
Email*
example@example.com
Is your home address the same?

Yes
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact on the family's Account*
Please type the first and last name of parent who will be primary on the account (only one parent is allowed as primary)
Insurance
Primary Insurance Carrier:*
Subscriber Name*
Subscriber ID #:*
Health Insurance Card : *

Browse Files
Upload the Front & Back Cancelof
Uninsured

Yes
Release of Medical Records
Medical Records Release : *

Browse Files
If you have your child's medical records, you may upload them here. If you don't, please click the link listed below, save and upload. Cancelof
https://www.pediatricsaroundthebend.com/_files/ugd/71a7cb_a27970887d014385abd5539dc0edee29.pdf

If you have any question please contact the office at (281)-499-6300

Patient Information
Patient Name #1*

First NameMiddle NameLast Name
Male/Female*
Date of Birth*

MonthDayYear
Date
Age
Lives With:*
Last well child visit:*
Does your child have any ongoing medical problems (i.e.. breathing problems, heart problems, seizures, asthma, ADHD/ADD..etc)? IF NONE, PLEASE TYPE NONE*
Patient Information

CHILD #2
Patient Name #2*

First NameMiddle NameLast Name
Male/Female*
Date of Birth*

MonthDayYear
Date
Age
Lives With:*
Last well child visit:*
Does your child have any ongoing medical problems (i.e.. breathing problems, heart problems, seizures, asthma, ADHD/ADD..etc)? IF NONE, PLEASE TYPE NONE*
Patient Information

CHILD #3
Patient Name #3*

First NameMiddle NameLast Name
Male/Female*
Date of Birth*

MonthDayYear
Date
Age
Lives With:*
Last well child visit:*
Does your child have any ongoing medical problems (i.e.. breathing problems, heart problems, seizures, asthma, ADHD/ADD..etc)? IF NONE, PLEASE TYPE NONE*
Patient Information

CHILD #4
Patient Name #4*

First NameMiddle NameLast Name
Male/Female*
Date of Birth*

MonthDayYear
Date
Age
Lives With:*
Last well child visit:*
Does your child have any ongoing medical problems (i.e.. breathing problems, heart problems, seizures, asthma, ADHD/ADD..etc)? IF NONE, PLEASE TYPE NONE*

Parent/Guardian Information
Parent/Guardian*

First NameLast Name
Phone Number*
Date of Birth*

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

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Information
Parent/Guardian*

First NameLast Name
Phone Number*
Date of Birth*

MonthDayYear
Date
Relationship to the patient:*
Male/Female*
Email*
example@example.com
Is your home address the same?

Yes
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact on the family's Account*
Please type the first and last name of parent who will be primary on the account (only one parent is allowed as primary)
Insurance
Primary Insurance Carrier:*
Subscriber Name*
Subscriber ID #:*
Health Insurance Card : *

Browse Files
Upload the Front & Back Cancelof
Uninsured

Yes
Release of Medical Records
Medical Records Release : *

Browse Files
If you have your child's medical records/newborn paperwork, you may upload them here. If you don't, please click the link listed below, save and upload. Cancelof
https://www.pediatricsaroundthebend.com/_files/ugd/71a7cb_a27970887d014385abd5539dc0edee29.pdf

If you have any question please contact the office at (281)-499-6300
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Patient Information

Parent/Guardian Information

Parent/Guardian Information

Insurance

Release of Medical Records

Patient Information

Patient Information

Parent/Guardian Information

Parent/Guardian Information

Insurance

Release of Medical Records

Patient Information

Patient Information

Patient Information

Parent/Guardian Information

Parent/Guardian Information

Insurance

Release of Medical Records

Patient Information

Patient Information

Patient Information

Patient Information

Parent/Guardian Information

Parent/Guardian Information

Insurance

Release of Medical Records