New Patient Enrollment Form

How did you hear about Treehouse Pediatrics?

Which provider are you wanting to be your Primary Care Provider?

Other

Treehouse Clinic is accepting new patients!

Dr O'Very is a pediatrician & Internal medicine doctor.

Emily Fonua is Dr O'Very's extender. She sees all ages of patients with Dr O'Very listed as the Attending/PCP

Dr Cohoon is a pediatrician.

All of the providers consult with Dr. O'Very often in order to maintain consistency in the practice! :)

Adults - We see any adult who has children in our practice! We are not currently growing our internal medicine population, so we will not be able to accept any adults without current or potential children in our pediatric practice!

Patient's Name

First NameLast Name

Date of Birth

MonthDayYear

Sex

Textable Number:

Format: (000) 000-0000.

E-mail

example@example.com

Billing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Any current concerns:

Taking any medications, currently?

If yes, please list it here

Where are you transferring care from?

Other

What facility are you transferring care from?

We need this for records requesting.

What facility are you transferring care from?

We need this for records requesting.

Do you have or have access to immunization records for your child(ren)?

Other

Please upload pictures or screenshots of the records here!

Primary Contact:

First NameLast Name

Relationship

Date of Birth

Date

Contact Number

Format: (000) 000-0000.

Marital Status

Secondary Contact:

First NameLast Name

Relationship

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth

Date

Insurance Provider

Just because its not listed, doesn't mean we don't take it!

We take majority of insurances! Those listed above are just most popular :)

Insurance Provider - Other than listed above

Member ID #

Group #

Upload A picture of their Insurance Card

Any more Patients that will be joining our practice?

Please put the Name, Gender, AND Date of Birth of any other patients that will be joining our practice! Or n/a if not applicable :)

By signing your name electronically on this Patient Information Form, you are agreeing that your electronic signature is the legal equivalent of your manual signature on this Form.