New Registration Form

1

Parent/Guardian's NameYour name

First Name

Last Name

2

Parent's Email AddressYour email address

example@example.com

3

Phone Number

Please enter a valid phone number.

4

Our practice doesn't take insurance for office visits. Instead, we simply collect a monthly membership fee which covers all your check-ups, sick visits, virtual visits, text messages, etc. We will collect your insurance information to keep on file for labs, x-rays, vaccines, etc.* This field is required.

Got it! ✅

5

Health Insurance Subscriber NameIf different than parent/guardian name already entered

First Name

Last Name

6

Subscriber Date of Birth

7

Primary Insurance Company

(BCBS, United Healthcare, etc)

8

Member ID/Policy Number

9

Group Number

10

On the next page, you will enter PARENT's information and then after you click to the next page, you'll press "Add Child" and then add each child.

Got it! ✅