Download New Patient Registration Forms

Dear Parents:

 

Welcome and thank you for choosing The Pediatric Center!

 

We accept most health insurance plans. Please contact your insurance carrier to verify that we are included in your plan.

 

We appreciate the opportunity to provide your child with the highest quality pediatric care. Please take a few minutes to fill out the following 5 forms as completely and accurately as possible and review our policies.
It is essential that we have, at a minimum, your child’s immunization record, before your first visit.

On the day of your appointment please bring with you:

 Your 5 completed registration forms
 Your insurance cards and photo identification (preferably driver’s license).
 Any prescription medicines your child is taking (in the original packaging).
 Any over-the-counter supplements your child is taking

We look forward to meeting you and your children. If you have any questions, please let us know at 908-508-0400.
Comments and suggestions are always welcome!

We accept most health insurance plans. Please contact our office to verify.

To view the forms listed below, you will need Adobe Reader. You may download Adobe Reader for free at www.adobe.com. Please bring your completed forms with you to our office at the time of your visit.

Registration Forms:

Family Registration Form
Family Registration Form
Family Health History
Family Health History Form
Payment Policy Form
Payment Policy Form
Authorize To Accompany Child
Authorization To Accompany Child
Privacy and Payment Acknowledgement
Acknowledgement of Payment and Privacy Policy

Our Office Policies:

Vaccine Policy
Vaccine Policy
Payment Policy Form
Payment Policy
Notice of Privacy Practices
Notice of Privacy Policy
Walk In Office Hours
Office Hours
Medical Forms
Medical Forms Policy
We Are Accepting Flu Vaccines By Appointment Only. Call To Schedule Your Child's Flu Shot Today! Call: (908) 508-0400
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