New Patient Information and Forms
The below information & forms will be needed prior to your child's first appointment with our office.
Future Pediatrics - New Patient Forms (English)
Future Pediatrics - Formularios de Paciente Nuevo (Espanol)
This packet includes the following documents:
- Patient Demographics, Parent/Guardian/Emergency Contact Information, Insurance Information
- Patient's Medical & Family History Questionnaire
- Authorization for Patient Transport
- Pediatric Office Policies
- Assignment of Insurance Benefits
- HIPAA Privacy Policy
- No-Smoking Policy
- Release of Medical Records Form (to request records from the previous medical provider)
In addition to the New Patient packet, we require a valid, government-issued, photo ID of the patient's parent/legal guardian to be brought to the first appointment for identification purposes.
Previous Medical Records & Immunization Records
We will need your child's medical records from all previously-seen providers
The last page of our New Patient packet includes a Release of Medical Records form. You will complete the form by listing all medical providers who have previously seen your child. We will then fax this form to those providers in order to request your child's prior medical records.
If your child is due for vaccinations or you will need the vaccination record for school/daycare purposes, we require the prior vaccination history (Shot Record).
This shot record can be sent from the previous medical provider, or the parent/guardian can provide a copy if they recieved it before transferring from that provider.
Newborn Hospital Discharge Summary
The Hospital Discharge Summary will include information critical to our continued care of your newborn infant.
The Discharge Summary should include information regarding your newborn infant's stay in the hospital. If your newborn was admitted into the NICU for any period of time, please be sure to include any additional Discharge Summary provided from the NICU.
