New Patient Registration Form
Policies
Please check off each box to accept the requirements that must be done before scheduling an appointment at Maeville Pediatrics
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PCP selection : Please let us know which physician will be your child's PCP (primary care physician). IF YOU DONT KNOW THATS OK! WE HAVE A GREAT TEAM AND JUST LEAVE BLANK.
Insurance Information (please add the policy you will be adding your baby to. If you will not be using insurance you can type 'self pay' in each blank.)
If different for each child please enter it when registering your child. If you are Self-Pay please proceed to next step.
Insurance Plan
*
Member ID#
*
Group#
*
Policy Holder Name
*
Policy Holder DOB
*
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Upload front and back of your chid's insurance card. If you have a newborn this can be the mother's insurance card and you can provide us with the child's card once they are added to the policy.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please enter your child's information (IF YOU HAVE NOT CHOSEN A NAME YET JUST PUT 'BABY (LAST NAME)
You will be able to add additional children in the next step
Name
*
First Name
Last Name
Gender (CLICK OTHER IF YOU ARE NOT FINDING OUT UNTIL BABY IS BORN)
*
Male
Female
Other
Date of Birth (OR EXPECTED DUE DATE)
*
-
Month
-
Day
Year
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Prefers not to answer
Do you need to register another child?
*
Yes, I'd like to register another child
No, please proceed to parent or guardian information
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Please register your second child
Enter the information for the next child you are registering. You can add additional children in the next step.
Name
*
First Name
Last Name
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Prefers not to answer
Is the insurance information different from the first child?
*
Yes
No
Insurance Plan
*
Member ID#
*
Group#
*
Policy Holder Name
*
Policy Holder DOB
*
Do you need to register another child?
*
Yes, I'd like to register another child
No, please proceed to parent or guardian information
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Next
Please register your third child
Enter the information for the next child you are registering. You can add additional children in the next step.
Name
*
First Name
Last Name
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Prefers not to answer
Is the insurance information different from the first child?
*
Yes
No
Insurance Plan
*
Member ID#
*
Group#
*
Policy Holder Name
*
Policy Holder DOB
*
Do you need to register another child?
*
Yes, I'd like to register another child
No, please proceed to parent or guardian information
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Next
Please register your forth child
Enter the information for the next child you are registering. You can add additional children in the next step.
Name
*
First Name
Last Name
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Prefers not to answer
Is the insurance information different from the first child?
*
Yes
No
Insurance Plan
*
Member ID#
*
Group#
*
Policy Holder Name
*
Policy Holder DOB
*
Do you need to register another child?
*
Yes, I'd like to register another child
No, please proceed to parent or guardian information
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Next
Please register your fifth child
Enter the information for the next child you are registering. This form allows a maximum of five registrations. You will need to complete a separate form if you need to add more children.
Name
*
First Name
Last Name
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Prefers not to answer
Is the insurance information different from the first child?
*
Yes
No
Insurance Plan
*
Member ID#
*
Group#
*
Policy Holder Name
*
Policy Holder DOB
*
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Parent or Guardian Information
Parent or Guardian #1
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Primary Phone Type
*
Cell
Landline
Email Address (this will be used to create your patient portal account)
*
example@example.com
Relationship to patient
Mother
Father
Stepmother
Stepfather
Grandmother
Grandfather
Other
Is there a second parent or guardian that should be listed on this account?
Yes
No
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Parent or Guardian Information
Parent or Guardian #2
Name
*
First Name
Last Name
Is their address the same as Parent/Guardian #1?
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
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Next
Primary Phone Type
*
Cell
Landline
Relationship to patient
Mother
Father
Stepmother
Stepfather
Grandmother
Grandfather
Other
Thank you for completing new patient registration form
Someone from our team will reach out to you at the phone number or email you have listed. If you do not hear back from us by next business day please call the office to schedule for first appointment, we look forward to welcoming you to Maeville Pediatrics!
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