Register - Drs' Pediatric

In order to be seen as a new patient at Doctors’ Pediatric there are just a few steps that need to be completed. Please call (203)762-3363 and our helpful staff will be able to answer any questions you may have. Once your questions have been addressed, you will be directed to our online new patient intake form below. (Alternatively you may download and mail the following → New Pt Intake Form (Printable PDF Version) Once submitted, we will confirm your insurance eligibility and contact you to review the information given and instruct you how to transfer any prior medical records (if you are coming to us from another practice).

Please know that for us to maintain the highest standard of care, we will need to have your medical records in our office for review prior to any well visits. We cannot schedule any well visit appointments until we have received your medical records.

Prior to your first visit, please download the forms listed below and bring them with you when you check in for your appointment. It’s as simple as that! Welcome to our practice. We look forward to caring for your child(ren).

Family Registration Form –Downloadable PDF
Credit and Collection Policy –Downloadable PDF
Notice of Privacy Practices –Downloadable PDF
Acknowledgement of Receipt of Privacy Practices –Downloadable PDF
Medical History Questionnaire –Downloadable PDF (please complete one for each child in your family)

New Patient Intake Form

On-line intake form for new families. There is also a PDF version which you can print out, complete and mail or deliver to the office. Thank you

Mother's Name
First Last
Mother’s DOB:
Date Format: MM slash DD slash YYYY
Father's Name
First Last
Father's DOB
Date Format: MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Mother's Cell
Father's Cell
Best phone to leave a message on?
- Home
- Mother's Cell
- Father's Cell
Email*
Name of Insurance Company:
Insurance ID#
Insurance provided though an employer?
- Yes
- No
Name of Responsible Parent:
Date of Birth
Date Format: MM slash DD slash YYYY
If you are expecting, which hospital do you plan to deliver at?
What is your due date?
Date Format: MM slash DD slash YYYY
Name of OB/GYN:
If you are a transfer, what practice are you transferring from?
What is the reason for leaving your current Practice?
Are your children up-to-date with their immunizations?
- Yes
- No
Were your children ever patients here before?
- Yes
- No
If yes, why did they leave?
Your Child/Children’s names:
Please list their names and all dates of birth. Thank you
Who may we thank for referring you to Doctors' Pediatric?
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

New Patient Intake Form

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