New Patient Registration Form

New Patient Registration

Please fill in the form below
Parent/Guardian # 1 Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian # 2 Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Email
Other Email
example@example.com
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Cell Number:

Name Phone Number
Secondary Cell Number:

Name Phone Number
Home Number:

Phone Number
Are you expecting?
Existing Child/Children's names, Date of Birth, M/F.
Do you have other children who will not be transferring to Baystreet Pediatrics?
Race
Ethnicity
Language preference
Were your children ever patients here before?
If you are expecting, which hospital do you plan to deliver at?
What is your due date?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If you are a transfer, what practice are you transferring from?
Practice phone number:
Practice fax number:
What is the reason for leaving your current practice?
We do require that our patients agree with the American Academy of Pediatrics vaccine recommendations. Are your children up-to-date with their immunizations and do you agree to follow the current AAP recommendations.
If No please explain why:
Name of Insurance Company
Name of Responsible Parent/Guardian

First NameLast Name
Date of Birth of Responsible Parent/Guardian

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insurance ID#
Insurance group #
Insurance provided through an employer?
Please upload a copy of your insurance card.

Browse Files

Cancelof
Who may we thank for referring you to Bay Street Pediatrics?
Relationship to Patient
Please upload your child's/children's Vaccine records

Browse Files

Cancelof
Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: