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 your family's 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.
Prior to registering your child or children with us, please review our financial and vaccine policies. These are found on our Small Town Pediatrics webpage.

if you do not wish to comply wih Small Town Pediatrics minimum vaccination requirements, we may not be your best fit for your family's pediatric care. Please consider seeking care with another medical provider. Our policy exists to protect our patient population, including pregnant moms. Many babies under our care are not yet eligible to be protected by vaccination and some children have serious medical conditions which increase their risks of harm from contracting a vaccine preventable disease.
Please indicate your perspective on vaccines

I want my child to receive protection from preventable disease with vaccines proven safe and effective to protect children and which have been a part of the vaccine recommendations for children for more than 10 years.I have questions about vaccines, and want to know more before I can decide.I will agree only to the minimum vaccines required by Small Town Pediatrics (Whooping Cough started not later than 4 months of age; Measles, Rubella and Chickenpox not later than 2 years of age)I will request a schedule for vaccination which is not the standard endorsed by the Advisory Committee on Immunization Practices.I do not wish for my child/children to have any vaccines.
Parent #1 (or Guardian #1) - Who Will Usually Make and Attend Appointments

First NameMiddle NameLast NameSuffix
Parent #1 or Guardian's Date of Birth

MonthDayYear
Parent/Guardian #1 Address:

Street Address

Street Address Line 2

CityState / 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
Parent #2 or (Guardian #2) - Who May Also Make Appointments

First NameMiddle NameLast NameSuffix
Parent #2 or Guardian's Date of Birth

MonthDayYear
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 NameLast 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 Small Town Pediatrics to 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. 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 this account. The only purpose is to make it possible to schedule appointments, communicate with you and bill for future medical services.

When you enroll, you will be directed to another form for medical records transfer. This form is needed for all children except newborn infants.
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!