Family Account Registration Form

Family Account Registration

This form collects information to create your family's account with Small Town Pediatrics. We need this information to schedule an appointment for your child or children. This information will also help us to set up a Patient Portal Account, and bill your insurance company directly for our services. If you already have an established account and only need to add an additional child or new baby, please send a patient portal message or call/text us at (503) 400-3852.
Parent #1 (or Guardian #1) - Who Will Usually Make and Attend Appointments

First Name Middle Name Last Name Suffix
Parent #1 or Guardians's Date of Birth

Month Day Year
Parent #2 or (Guardian #2) - Who May Also Make Appointments

First Name Middle Name Last Name Suffix
Parent/Guardian #1 Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone Number:
The primary phone number is your:
May we use this number for text messaging?
E-mail
example@example.com
May we send you e-mail notifications, updates and newsletters?
What is your family's preferred language (language used at home)?
Would like an interpreter to help with patient visits and communication with the office
Please provide an emergency contact. We may need to we need to urgently contact you with information about your child. If we are unable to reach a parent or guardian, who should we contact?
Emergency Contact:

First Name Last Name
Emergency Contact Number
How many children are you registering with Small Town Pediatrics? *
How many children being registered have health insurance coverage? *

Almost Done!

The information provided on this secure form will allow Small Town Pediatrics to register your family with us. When your account is set up, we will be able to schedule appointments, and give you access to our Patient Portal
By clicking "ENROLL" below, you are requesting that Small Town Pediatrics create a family account for you and your child or children. To complete this process we may need to contact you by phone, text or email for clarification or additional information.

If you have additional children to enroll, primary insurance plans or "secondary insurance" we will follow-up with you to collect that additional information. In some cases we may wait to follow-up until a child has an appointment with us.

There is no charge to you nor your insurance for setting up these accounts. The only purpose is to make it possible to schedule appointments, communicate with you and bill for future medical services.
Should be Empty:

Family Account Registration

Information on Your Family's Primary Insurance Policy

Children Covered by This Insurance Plan:

Second "Primary" Insurance Policy Information

Children Covered by This Insurance Plan:

Almost Done!