Newborn Application

Saugatuck Pediatrics shares the excitement and joy of expecting a child. Our doctors are more than happy to set up a Prenatal Consult with you via telehealth or phone to briefly discuss the practice and address any questions you may have.

To read about the physicians in our practice, visit www.saugatuckpeds.com.

If you are interested in making Saugatuck Pediatrics your child’s medical home, please complete this survey so we can ensure that we are a good match for you.

Please also see the “Are We a Good Fit” page on our website to ensure that you are aware of our policies. A member of our office will contact you within a week after receipt of the survey to discuss appointment availabilities.

*Filling out an application does not guarantee acceptance into the practice.

Parent 1*

First NameLast Name

Parent 2

First NameLast Name

Email*

example@example.com

Best Contact Number*

Please enter a valid phone number.

By checking this box you agree to receive text messages from Saugatuck Pediatrics, you can reply stop to opt-out anytime.

Due Date*

Date

Are you pregnant with multiples?*

Is this your first child? If no, please list the names and ages of your other children below:*

Name

First NameLast Name

Age

Name

First NameLast Name

Age

Name

First NameLast Name

Age

What is your insurance? Saugatuck Pediatrics participates with Aetna, Anthem Blue Cross Blue Shield, Cigna, Multiplan and Connecticare. If you have Empire BCBS please check with your specific plan to see if we are listed. We do not at this time accept (exchange) plans other than Connecticare. We hope to be open to United/Oxford patients as of January 2024. Many patients do come to us out of network. Please note that patients who are out of network are expected to pay for the full cost of the visit at the time of service.*

Name of Obstetrician*

First NameLast Name

Hospital where you will deliver:*

Are you willing to adhere to the Academy of Pediatrics and CDC recommended vaccine schedule:*

Have you read and do you agree with the “Are We a Good Fit” checklist?:*

Are you comfortable paying our annual administrative fee yearly? (not applicable for Husky patients)*

Which pediatrician would you like to join with?

Whom can we thank for referring you?

First NameLast Name