New Patient Pre-Registration Form

Policies

We encourage you to visit the policies page on our website to read all of our policies in full. Please take a moment to read a quick overview of some policies we would like you to know before registering.

Scheduling Your First Appointment

In order to schedule your first visit, we must receive your medical records from the previous office you attended. You will be directed to a medical record release form after submitting your registration form. We will send the form to your previous office on your behalf. Once your records are received, we will contact you to schedule your appointment.

Vaccine Policy

At Olney Pediatrics, we strongly believe that all patients in our practice should be vaccinated according to the annually published Centers for Disease Control and Prevention (CDC) recommendations. Unless there is a valid medical exemption, all patients in our practice must receive all immunizations required by the state of Maryland for school attendance, according to the schedule of doses published annually by the CDC.

Missed Appointments

If you cancel less than 1 business day in advance for a Well Child, ADHD, or Behavioral Health visit; or if you "no show" for any type of appointment, there is a service charge of either $50 or $25, depending on the visit type.

Copays

Co-Payments are due at the time of service. Full co-payment is expected at the time services are rendered and for all past due balances unless prior financial arrangements have been made with our billing staff. Co-Payments are due regardless of who brings the child in for the service.

Form Fees

We are happy to fill out standard school physical forms, daycare attendance forms, camp physical forms, school asthma action plans, medication forms, and anaphylaxis/food allergy plans; if your child's physical is up-to-date. Form completion may take 3 to 5 business days after receipt of forms to be completed.
A charge of $20 will be assessed per child for each request by the parent (certain forms are completed at no charge).

Please Enter Your Child's Information

You will be able to add additional children in the next step

Patient Portal Access for Patients 11y-17yr

For our patients between the ages of 11 and 17, we have CHADIS (Child Health and Development Interactive System) questionnaires for BOTH the parents and patients. For that reason, we would like to register the minor child with their own portal access in order to access their questionnaires as both sets cannot be sent to the same Patient Portal.  You may opt out of this.

Please Enter Your 2nd Child's Information

You will be able to add additional children in the next step

Patient Portal Access for Patients 11y-17yr

 

Please Enter Your 3rd Child's Information

You will be able to add additional children in the next step

Patient Portal Access for Patients 11y-17yr

 

Please Enter Your 4th Child's Information

You will be able to add additional children in the next step

Patient Portal Access for Patients 11y-17yr

 

Please Enter Your 5th Child's Information

You will be able to add additional children in the next step

Patient Portal Access for Patients 11y-17yr

 

Patient Portal Access for Parents/Guardians

To better serve our patients, our office has established a Patient Portal for some forms of communication. The Patient Portal is a simple way to access your child’s health information online. In addition, the Patient Portal allows you to:
• View upcoming appointments
• View and print immunization records for school and day care
• Request prescription refills
• Retrieve test/lab results
• View balances
• Make secure credit card payments for balances
• Communicate with our office by sending and receiving secure messages regarding lab results, medical questions, medication refill requests, referral requests.

We participate in a program called CHADIS – Child Health And Development Interactive System, and have recently linked the questionnaires with our Patient Portal. Each Portal user will be invited to complete questionnaires prior to certain visit types.

 

Patient Portal Access for Parents/Guardians

 Optional for second parent/guardian

You are now ready to submit this form. If you are transferring from another office, please complete the Medical Records Release Form found on the next page (after clicking "Submit" below) unless you already have the medical records or have requested the transfer of records from the previous office yourself. Please explain in the box below if you will not be completing a Release Form.  

We will contact you to schedule once the records have been received.