New Patient Application

New Patient Application

Kids R Us Pediatrics • 121 Golfview Dr. NE, Arab, AL 35016 • (256) 931-KIDS
Thank you for your interest in joining our practice and entrusting the care of your child to us!

This form contains the following sections:
1. Office Policies
2. Are You Expecting?
3. Patient Demographics
4. Insurance
5. Parents or Guardians
Please gather your personal information. We will need your child’s name and date of birth, your name, address, phone number, e-mail address, and insurance information.
Today

MonthDayYear
Date

Office Policies

Your child’s care is a partnership between the family and provider. We believe it is best to clearly define our practice policies up front so we can focus on what is most important: your child’s health. In order to proceed, you must first review and agree to our office policies.
Office Hours
- Monday–Thursday 8:00am–4:00pm
- Friday 8:00am–12:00pm
- Our office is closed on all major holidays.
Office Hours*

I have read and agree to this policy of Kids R Us Pediatrics.
Vaccines

Kids R Us Pediatrics follows the recommendations of the American Academy of Pediatrics as well as the CDC’s Advisory Committee on Immunization Practice (ACIP).

We do not accept families who are unwilling to adhere to these immunization schedules.
Vaccines*

I have read and agree to this policy of Kids R Us Pediatrics.
Prescriptions

Antibiotics treat bacterial infections, but not all illnesses are caused by bacteria. Most illnesses in children are caused by viruses. We do not typically prescribe antibiotics over the phone or without an office exam or telemedicine visit.
Prescriptions*

I have read and agree to this policy of Kids R Us Pediatrics.
Appointments

We see patients by appointment, we are not a walk-in clinic. We offer same day sick appointments for established patients. If we are unable to accommodate we will offer the first available on the next day for acute issues.

If you are running late for your appointment, please let us know, we may ask you to reschedule. All upcoming appointments are visible in your patient portal, and we call or send reminders prior to each appointment.
Appointments*

I have read and agree to this policy of Kids R Us Pediatrics.
Missed Appointments/No-Shows

If you are unable to make your appointment, please let us know immediately so that others may be seen. Missed appointments without appropriate notice may incur a $50 No-Show fee. Repeated missed appointments will result in dismissal from the practice.
Missed Appointments/No-Shows*

I have read and agree to this policy of Kids R Us Pediatrics.
Well-Child Visits

Annual well visits are a vital part of your child’s overall health. We follow evidence based preventative guidelines and use these well visits to evaluate your child’s growth and development to make sure they are meeting appropriate milestones. We also perform age appropriate screenings for vision, hearing, and mental and emotional health. Well child visits are required at regular intervals until age 2 and annually thereafter for our patients.

Well-Child Visit Schedule
- Newborn
- 2 Weeks/1 Month
- 2 Months
- 4 Months
- 6 Months
- 9 Months
- 12 Months
- 15 Months
- 18 Months
- 2 Years
- 2.5 Years
- 3–18 Years *Once per calendar year
Well-Child Visits*

I have read and agree to this policy of Kids R Us Pediatrics.
Portal Messages and After-Hours Calls

Each account should have at least one portal user. Portal messages are to be used for NON-Emergent reasons only. Appointment Requests, medication questions, or other non-emergent questions can be sent through the patient portal. Messages are monitored continuously during office-hours and periodically after hours.

After-hours phone calls will be answered and routed through our Nurse Triage Line. The Nurse-line can reach Dr. Miller and/or Ms. Katie in the case of an emergency.
Portal Messages and After-Hours Calls*

I have read and agree to this policy of Kids R Us Pediatrics.
Financial Obligations and Insurance

Co-Pays are due at the time of your visit regardless of who brings the child in for the visit. The co-pay amount is determined by your insurance company and is a contract between you and the insurance company. The insurance company requires that we collect your co-pay at the time of your appointment. We cannot waive co-pays as this would be insurance fraud.

Our office participates with a variety of insurance plans. Every policy is different. It is your responsibility to understand your policy, your expected co-pay, and any deductible amounts that may apply. Payment options are available through the portal if you wish to pay your co-pay ahead of an office visit or make payments towards your balance. Balances due must be paid in a timely manner. Accounts carrying a delinquent balance may be assessed a monthly finance charge. If you fail to make payment and your account becomes delinquent, your account may be sent to collections and your children may be dismissed from the practice.

New parents will need to contact your employer and/or insurance company to inform them of the birth of your baby. If you do not do so within a specified timeframe (typically 30 days from birth) you may be financially responsible for a larger portion of your inpatient stay and first few visits.

If your insurance provider requires you to select a primary care physician, you will need to notify them prior to your first visit with us.

Any change in insurance must be provided to our office as soon as possible to prevent billing issues.

As medical providers our relationship is with you and your child, not your insurance company. Filing insurance claims is a courtesy we extend, but all charges are ultimately your responsibility from the date that services are rendered. It is in your best interest to be familiar with your specific plan benefits and coverage. Our responsibility is to provide your child with the best care possible. If that includes treatment or medication that is not covered by your insurance, then you will be expected to pay for those services.
Financial Obligations and Insurance*

I have read and agree to this policy of Kids R Us Pediatrics.
By clicking "I Agree" below I acknowledge that I have read and agree to abide by the above policies of Kids R Us Pediatrics. I understand that not adhering to the policies may result in dismissal as a patient of Kids R Us Pediatrics.

Are You Expecting?
Is this application for a newborn?*

Yes - the baby has already been bornYes - the baby has NOT yet been bornNo
Waiting List

At this time, we are on a waiting list for new patients. We are continuously reviewing the list. Please complete the rest of this form and someone from our office will contact you once a spot comes available.
Congratulations!

We love babies and cannot wait to meet yours. Our system does not allow us to create a new Patient Portal account until the child has been born. Please continue and fill out the contact information in the next section and someone from our office will contact you prior to your due date.
What is your child's date of birth?*

MonthDayYear
Date
What is your child's due date?*

MonthDayYear
Date

Patient Demographics: Child 1

Please enter your child's information. You will be able to register up to five children on this form. To register additional children, please complete a second application form.
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Sex*

FemaleMale
Age*
For children 13 and older, please provide a mobile phone number and/or email address to be used for their patient portal account.
Mobile Phone Number
Please enter a valid phone number.
Email
example@example.com
What is the approximate date of this child's last wellness exam? *
Month and year are sufficient
Is this child current on their vaccines?*

YesNo
Do you need to register another child?*

YesNo

Patient Demographics: Child 2

Please enter your child's information.
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Sex*

FemaleMale
Age*
For children 13 and older, please provide a mobile phone number and/or email address to be used for their patient portal account.
Mobile Phone Number
Please enter a valid phone number.
Email
example@example.com
What is the approximate date of this child's last wellness exam? *
Month and year are sufficient
Is this child current on their vaccines?*

YesNo
Do you need to register another child?*

YesNo

Patient Demographics: Child 3

Please enter your child's information.
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Sex*

FemaleMale
Age*
For children 13 and older, please provide a mobile phone number and/or email address to be used for their patient portal account.
Mobile Phone Number
Please enter a valid phone number.
Email
example@example.com
What is the approximate date of this child's last wellness exam? *
Month and year are sufficient
Is this child current on their vaccines?*

YesNo
Do you need to register another child?*

YesNo

Patient Demographics: Child 4

Please enter your child's information.
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Sex*

FemaleMale
Age*
For children 13 and older, please provide a mobile phone number and/or email address to be used for their patient portal account.
Mobile Phone Number
Please enter a valid phone number.
Email
example@example.com
What is the approximate date of this child's last wellness exam? *
Month and year are sufficient
Is this child current on their vaccines?*

YesNo
Do you need to register another child?*

YesNo

Patient Demographics: Child 5

Please enter your child's information.
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Sex*

FemaleMale
Age*
For children 13 and older, please provide a mobile phone number and/or email address to be used for their patient portal account.
Mobile Phone Number
Please enter a valid phone number.
Email
example@example.com
What is the approximate date of this child's last wellness exam? *
Month and year are sufficient
Is this child current on their vaccines?*

YesNo
To register additional children, please complete another application.

Parents or Legal Guardians

Please enter the contact information for the child's parents or legal guardians.
Parent/Legal Guardian 1*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Legal Guardian 2

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address

The address is the same as for Parent 1
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Submit Your Application

Thank you for completing this application, you are almost finished!
Parent Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Hospital
How did you hear about us? Who referred you?*
Waiting List

I understand that by joining the waiting list I am not registering as a patient of Kids R Us Pediatrics and are not guaranteed acceptance into the practice. I will still need to maintain a primary care doctor for my children with their current pediatrician.
Should be Empty:

New Patient Application

Office Policies

Office Hours

Vaccines

Prescriptions

Appointments

Missed Appointments/No-Shows

Well-Child Visits

Well-Child Visit Schedule

Portal Messages and After-Hours Calls

Financial Obligations and Insurance

Are You Expecting?

Waiting List

Congratulations!

Patient Demographics: Child 1

Patient Demographics: Child 2

Patient Demographics: Child 3

Patient Demographics: Child 4

Patient Demographics: Child 5

Insurance

Insurance for Child 1

Insurance for Child 2

Insurance for Child 3

Insurance for Child 4

Insurance for Child 5

Parents or Legal Guardians

Submit Your Application

Waiting List