• New Patient Registration Form

    Policies

  • Please check off each box to accept the requirements that must be done before scheduling an appointment at Maeville Pediatrics

  • Insurance Information

    If different for each child please enter it when registering your child. If you are Self-Pay please proceed to next step.

  • Please enter your child's information

    You will be able to add additional children in the next step
  •  - -
    Pick a Date

  • Patient Portal Access for Ages 13+


    Due to privacy laws, we can only grant partial patient portal access to parents or legal guardians of patients aged 13 and older. This is to ensure confidentiality between the patient and his or her pediatrician. Parents or legal guardians of patients age 18 and older can obtain access to certain features only with signed permission from the patient.

    We ask that you please give an email address or cell phone number for the child so that we can create a patient portal account for them. This will give them access to their medical information, the ability to privately message the doctor, and forms that will need to be completed prior to appointments. We will also create a parent account with partial access. If the child wants to grant full access to the parent, they can sign a release form in the office.

  • Please register your second child

    Enter the information for the next child you are registering. You can add additional children in the next step.
  •  - -
    Pick a Date

  • Patient Portal Access for Ages 13+


    Due to privacy laws, we can only grant partial patient portal access to parents or legal guardians of patients aged 13 and older. This is to ensure confidentiality between the patient and his or her pediatrician. Parents or legal guardians of patients age 18 and older can obtain access to certain features only with signed permission from the patient.

    We ask that you please give an email address or cell phone number for the child so that we can create a patient portal account for them. This will give them access to their medical information, the ability to privately message the doctor, and forms that will need to be completed prior to appointments. We will also create a parent account with partial access. If the child wants to grant full access to the parent, they can sign a release form in the office.

  • Please register your third child

    Enter the information for the next child you are registering. You can add additional children in the next step.
  •  - -
    Pick a Date

  • Patient Portal Access for Ages 13+


    Due to privacy laws, we can only grant partial patient portal access to parents or legal guardians of patients aged 13 and older. This is to ensure confidentiality between the patient and his or her pediatrician. Parents or legal guardians of patients age 18 and older can obtain access to certain features only with signed permission from the patient.

    We ask that you please give an email address or cell phone number for the child so that we can create a patient portal account for them. This will give them access to their medical information, the ability to privately message the doctor, and forms that will need to be completed prior to appointments. We will also create a parent account with partial access. If the child wants to grant full access to the parent, they can sign a release form in the office.

  • Please register your forth child

    Enter the information for the next child you are registering. You can add additional children in the next step.
  •  - -
    Pick a Date

  • Patient Portal Access for Ages 13+


    Due to privacy laws, we can only grant partial patient portal access to parents or legal guardians of patients aged 13 and older. This is to ensure confidentiality between the patient and his or her pediatrician. Parents or legal guardians of patients age 18 and older can obtain access to certain features only with signed permission from the patient.

    We ask that you please give an email address or cell phone number for the child so that we can create a patient portal account for them. This will give them access to their medical information, the ability to privately message the doctor, and forms that will need to be completed prior to appointments. We will also create a parent account with partial access. If the child wants to grant full access to the parent, they can sign a release form in the office.

  • Please register your fifth child

    Enter the information for the next child you are registering. This form allows a maximum of five registrations. You will need to complete a separate form if you need to add more children.
  •  - -
    Pick a Date

  • Patient Portal Access for Ages 13+


    Due to privacy laws, we can only grant partial patient portal access to parents or legal guardians of patients aged 13 and older. This is to ensure confidentiality between the patient and his or her pediatrician. Parents or legal guardians of patients age 18 and older can obtain access to certain features only with signed permission from the patient.

    We ask that you please give an email address or cell phone number for the child so that we can create a patient portal account for them. This will give them access to their medical information, the ability to privately message the doctor, and forms that will need to be completed prior to appointments. We will also create a parent account with partial access. If the child wants to grant full access to the parent, they can sign a release form in the office.

  • Parent or Guardian Information

    Parent or Guardian #1

  • Parent or Guardian Information

    Parent or Guardian #2

  • Thank you for completing new patient registration form

    Please call the office to schedule for first appointment, we look forward to welcoming you to Maeville Pediatrics!

  • One last thing

    Just another minute and you'll be done
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