Registration (Do Not Use)

1
💉 Vaccine Policy

At Peak Pediatric Care, we are pro-vaccination and follow the vaccine schedule recommended by the American Academy of Pediatrics.

Our policies are designed with the safety and well-being of our patients in mind. Therefore:

We require patients to adhere to the Massachusetts School Immunization Requirements as part of their care at Peak.

We do not allow custom schedules or vaccine spacing, as this can lead to errors that may put patients at risk.

The Influenza, COVID, Hepatitis A, and HPV vaccines are not required at Peak, as they are not part of the Massachusetts School Immunization Requirements.

If you choose not to vaccinate your child according to these requirements, our practice is not the right fit for your family.
2
Do you agree to follow our vaccine policy?* This field is required.
YES, I AgreeNO
3
📆 Appointment Policy

We understand that life happens, and unexpected situations may cause you to miss an appointment. To better serve all our patients, we ask for at least 24 hours' notice if you need to cancel or reschedule. This allows us to offer your slot to someone else in need.

Here’s how our policy works:

First Missed Appointment: You’ll receive a reminder of our policy.

Subsequent Missed Appointments: If proper notice isn’t given, a $40 missed appointment fee will be applied. This fee must be paid before scheduling another appointment.

Repeated Missed Appointments: Missing three appointments within 12 months may result in dismissal from our practice.

While we understand that unforeseen circumstances can occur, this policy is necessary due to a rise in missed appointments. We appreciate your understanding and cooperation as we strive to provide timely care for all our patients.
4
Do you agree to follow our appointment policy?* This field is required.
YES, I AgreeNO
5
💳 Billing Policy

We ask all patients to pay their bills in full within 30 days of receiving a statement. Please contact our office to set up a payment plan if you need additional time. For added convenience, consider enrolling in our Peak Pay program, which allows you to keep a credit card on file for timely payments securely.

Here’s what happens if a balance remains unpaid:

90 Days: A $25 late fee will be added to your account.

120 Days: Your account will be inactive until the balance is paid. Scheduled appointments will be canceled, and no new appointments will be made. Accounts overdue at this stage will be reviewed for collections.

Important Reminder: Before your first appointment, it is your responsibility to confirm that Peak Pediatric Care is in-network with your insurance. If your insurance is not accepted and you proceed with a visit, you will be responsible for the full cost.
6
Do you agree to follow our billing policy?* This field is required.
YES, I AgreeNO
7
Verify Insurance Coverage

We ask all patients to confirm with their health insurance that Peak Pediatric Care is in-network for their specific plan. You are responsible for verifying network status, as our office cannot do this on your behalf. If you do not confirm we are in-network, you may be responsible for the full balance of any visits.

Please note: We are not currently in-network with Neighborhood Health Plan. We are applying and hope to accept it soon, but cannot complete registrations until approval is finalized.
8
What is your primary insurance?* This field is required.We do not currently accept Neighborhood Health Plan
Aetna
Blue Cross Blue Shield
Cigna
Harvard Pilgrim
MassHealth / WellSense (Medicaid)
Tufts
United Healthcare
Other
9
MassHealth / WellSense

You must contact MassHealth to select the WellSense MCO plan and designate Dr. Kathryn Hansen at Peak Pediatric Care as the PCP.

We cannot complete your registration until we confirm the correct plan and PCP are listed on your account. Once you have confirmed you are on the WellSense MCO plan, please contact our office so we can process your registration.
10
Do you have the Tufts Health Together plan through MassHealth?* This field is required.
YESNO
11
Who is listed as the subscriber on the insurance?* This field is required.
Full Name
Subscribers Date of Birth
12
Are you able to take a photo of your insurance card now?* This field is required.
YESNO
13
Please upload a photo showing the FRONT of your insurance card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
14
Please upload a photo showing the BACK of your insurance card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
15
Do you have a secondary insurance policy?* This field is required.
YESNO
16
What is your secondary insurance?* This field is required.
Aetna
Blue Cross Blue Shield
Cigna
Harvard Pilgrim
MassHealth / WellSense (Medicaid)
Tufts
United Healthcare
Other
17
Who is listed as the subscriber on the insurance?* This field is required.
Full Name
Subscribers Date of Birth
18
MassHealth / WellSense

You must contact MassHealth to select the WellSense MCO plan and designate Dr. Kathryn Hansen at Peak Pediatric Care as the PCP.

We cannot complete your registration until we confirm the correct plan and PCP are listed on your account. Once you have confirmed you are on the WellSense MCO plan, please contact our office so we can process your registration.
19
Do you have the Tufts Health Together plan through MassHealth?* This field is required.
YESNO
20
Are you able to take a photo of your insurance card now?* This field is required.
YESNO
21
Please upload a photo showing the front of your insurance card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
22
Please upload a photo showing the back of your insurance card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
23
Are you transferring your child/children from another office, or are you pre-registering a newborn baby?* This field is required.
👧 Transferring to Peak👶 Newborn Baby
24
Do you have other children already registered at Peak?* This field is required.
YESNO
25
Please list their name(s) and date of birth, and we can be sure to connect your newborn to the same account.* This field is required.
26
Have you already delivered or are you currently expecting?* This field is required.
DeliveredExpecting
27
What is your child's legal name as listed on your insurance?* This field is required.
First Name
Middle Name
Last Name
28
Gender* This field is required.
MaleFemale
29
When was {whatIs97[1]} born?* This field is required.
Date
Month
Day
Year
30
Would you prefer {whatIs97[1]} to be called by a shortened name or nickname?* This field is required.
YESNO
31
What name would you like {whatIs97[1]} to be called in the office?* This field is required.
Preferred Name or Nickname
32
What hospital did you deliver at?* This field is required.
33
What is your expected due date?* This field is required.
Date
Year
Month
Day
34
Which hospital will you be delivering at?* This field is required.
35
Do you have a name picked yet for your child?* This field is required.
YESNO
36
What is your child's legal name as it will appear on your insurance?* This field is required.Don't worry, this can be updated at your first appointment if you change your mind 😀
First Name
Middle Name
Last Name
37
Would you prefer {whatIs98[1]} to be called by a shortened name or nickname?* This field is required.
YESNO
38
What name would you like {whatIs98[1]} to be called in the office?* This field is required.
Preferred Name or Nickname
39
Do you know the gender of your child?* This field is required.
YESNO
40
What is your child's gender?* This field is required.
MaleFemale
41
Please select your child's race* This field is required.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Prefer not to answer
42
Please select your child's ethnicity* This field is required.
Hispanic or Latino
Not Hispanic or Latino
Prefer not ot answer
43
Please enter your preferred language* This field is required.
44
Are you expecting more than one child?* This field is required.
YESNO
45
Let us know how many children you are expecting. If you already know names and gender, please include it here. This will allow us to create all of their accounts.* This field is required.
46
Do you need to register more than one newborn?* This field is required.
YESNO
47
You can add the other newborn(s) full name and gender below. One per line.* This field is required.
48
Are you transferring other children to Peak?* This field is required.
YESNO
49
Which office are you transferring from?* This field is required.
Please include office name and location
50
What is your child's legal name as it appears on your insurance?* This field is required.
First Name
Middle Name
Last Name
51
Gender* This field is required.Per insurance requirements, we must record your child’s assigned gender at birth. However, we’re happy to include their preferred gender, pronouns, and name in their chart. You’ll be able to provide this information as you complete the form.
MaleFemale
52
Current Date
Date
Month
Day
Year
53
Date of Birth* This field is required.
Date
Month
Day
Year
54
Age
55
Does {name1:first} have a nickname or a preferred name they like to go by?* This field is required.
YESNO
56
Which name would {name1:first} prefer to be called in the office?* This field is required.
Preferred Name or Nickname
Please Select
Please Select
Preferred Name
Nickname
57
We want all our patients to feel welcome at Peak. Is there anything we should know that would help your child feel at ease?* This field is required.This could include gender identity, preferred pronouns, needle phobia, or anything else you feel we should know.
YESNO
58
Please share any information that will help us provide the best care for your child and make them feel comfortable and at ease.* This field is required.
59
We ask that all patients 12 and older have their own patient portal account. Would you like to set up {name1:first}'s account using their cell number or email address?* This field is required.This allows your child to complete required paperwork before their visit, saving time. It also gives them direct access to message their provider with any questions or concerns.
Cell Number
Email
Neither
60
What is {name1:first}'s cell number?* This field is required.
61
What is {name1:first}'s email address?* This field is required.
62
Please select {name1:first}'s race* This field is required.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Prefer not to answer
63
Please select {name1:first}'s ethnicity* This field is required.
Hispanic or Latino
Not Hispanic or Latino
Prefer not ot answer
64
What is {name1:first}'s preferred language?* This field is required.
65
Do you have another child to register?
YESNO
66
What is your child's legal name as it appears on your insurance?* This field is required.
First Name
Middle Name
Last Name
67
Gender* This field is required.Per insurance requirements, we must record your child’s assigned gender at birth. However, we’re happy to include their preferred gender, pronouns, and name in their chart. You’ll be able to provide this information as you complete the form.
MaleFemale
68
Current Date
Date
Month
Day
Year
69
Date of Birth* This field is required.
Date
Month
Day
Year
70
Age
71
Does {name2:first} have a nickname or a preferred name they like to go by?* This field is required.
YESNO
72
Which name would {name2:first} prefer to be called in the office?* This field is required.
Preferred Name or Nickname
Please Select
Please Select
Preferred Name
Nickname
73
We want all our patients to feel welcome at Peak. Is there anything we should know that would help your child feel at ease?* This field is required.This could include gender identity, preferred pronouns, needle phobia, or anything else you feel we should know.
YESNO
74
Please share any information that will help us provide the best care for your child and make them feel comfortable and at ease.* This field is required.
75
We ask that all patients 12 and older have their own patient portal account. Would you like to set up {name2:first}'s account using their cell number or email address?* This field is required.This allows your child to complete required paperwork before their visit, saving time. It also gives them direct access to message their provider with any questions or concerns.
Cell Number
Email
Neither
76
What is {name2:first}'s cell number?* This field is required.
77
What is {name2:first}'s email address?* This field is required.
78
Please select {name2:first}'s race* This field is required.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Prefer not to answer
79
Please select {name2:first}'s ethnicity* This field is required.
Hispanic or Latino
Not Hispanic or Latino
Prefer not ot answer
80
What is {name2:first}'s preferred language?* This field is required.
81
Do you have another child to register?
YESNO
82
What is your child's legal name as it appears on your insurance?* This field is required.
First Name
Middle Name
Last Name
83
Gender* This field is required.Per insurance requirements, we must record your child’s assigned gender at birth. However, we’re happy to include their preferred gender, pronouns, and name in their chart. You’ll be able to provide this information as you complete the form.
MaleFemale
84
Current Date
Date
Month
Day
Year
85
Date of Birth* This field is required.
Date
Month
Day
Year
86
Age
87
Does {name3:first} have a nickname or a preferred name they like to go by?* This field is required.
YESNO
88
Which name would {name3:first} prefer to be called in the office?* This field is required.
Preferred Name or Nickname
Please Select
Please Select
Preferred Name
Nickname
89
We want all our patients to feel welcome at Peak. Is there anything we should know that would help your child feel at ease?* This field is required.This could include gender identity, preferred pronouns, needle phobia, or anything else you feel we should know.
YESNO
90
Please share any information that will help us provide the best care for your child and make them feel comfortable and at ease.* This field is required.
91
We ask that all patients 12 and older have their own patient portal account. Would you like to set up {name3:first}'s account using their cell number or email address?* This field is required.This allows your child to complete required paperwork before their visit, saving time. It also gives them direct access to message their provider with any questions or concerns.
Cell Number
Email
Neither
92
What is {name3:first}'s cell number?* This field is required.
93
What is {name3:first}'s email address?* This field is required.
94
Please select {name3:first}'s race* This field is required.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Prefer not to answer
95
Please select {name3:first}'s ethnicity* This field is required.
Hispanic or Latino
Not Hispanic or Latino
Prefer not ot answer
96
What is {name3:first}'s preferred language?* This field is required.
97
Do you have another child to register?
YESNO
98
What is your child's legal name as it appears on your insurance?* This field is required.
First Name
Middle Name
Last Name
99
Gender* This field is required.Per insurance requirements, we must record your child’s assigned gender at birth. However, we’re happy to include their preferred gender, pronouns, and name in their chart. You’ll be able to provide this information as you complete the form.
MaleFemale
100
Current Date
Date
Month
Day
Year
101
Date of Birth* This field is required.
Date
Month
Day
Year
102
Age
103
Does {name4:first} have a nickname or a preferred name they like to go by?* This field is required.
YESNO
104
Which name would {name4:first} prefer to be called in the office?* This field is required.
Preferred Name or Nickname
Please Select
Please Select
Preferred Name
Nickname
105
We want all our patients to feel welcome at Peak. Is there anything we should know that would help your child feel at ease?* This field is required.This could include gender identity, preferred pronouns, needle phobia, or anything else you feel we should know.
YESNO
106
Please share any information that will help us provide the best care for your child and make them feel comfortable and at ease.* This field is required.
107
We ask that all patients 12 and older have their own patient portal account. Would you like to set up {name4:first}'s account using their cell number or email address?* This field is required.This allows your child to complete required paperwork before their visit, saving time. It also gives them direct access to message their provider with any questions or concerns.
Cell Number
Email
Neither
108
What is {name4:first}'s cell number?* This field is required.
109
What is {name4:first}'s email address?* This field is required.
110
Please select {name4:first}'s race* This field is required.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Prefer not to answer
111
Please select {name4:first}'s ethnicity* This field is required.
Hispanic or Latino
Not Hispanic or Latino
Prefer not ot answer
112
What is {name4:first}'s preferred language?* This field is required.
113
Do you have another child to register?
YESNO
114
What is your child's legal name as it appears on your insurance?* This field is required.
First Name
Middle Name
Last Name
115
Gender* This field is required.Per insurance requirements, we must record your child’s assigned gender at birth. However, we’re happy to include their preferred gender, pronouns, and name in their chart. You’ll be able to provide this information as you complete the form.
MaleFemale
116
Current Date
Date
Month
Day
Year
117
Date of Birth* This field is required.
Date
Month
Day
Year
118
Age
119
Does {name5:first} have a nickname or a preferred name they like to go by?* This field is required.
YESNO
120
Which name would {name5:first} prefer to be called in the office?* This field is required.
Preferred Name or Nickname
Please Select
Please Select
Preferred Name
Nickname
121
We want all our patients to feel welcome at Peak. Is there anything we should know that would help your child feel at ease?* This field is required.This could include gender identity, preferred pronouns, needle phobia, or anything else you feel we should know.
YESNO
122
Please share any information that will help us provide the best care for your child and make them feel comfortable and at ease.* This field is required.
123
We ask that all patients 12 and older have their own patient portal account. Would you like to set up {name5:first}'s account using their cell number or email address?* This field is required.This allows your child to complete required paperwork before their visit, saving time. It also gives them direct access to message their provider with any questions or concerns.
Cell Number
Email
Neither
124
What is {name5:first}'s cell number?* This field is required.
125
What is {name5:first}'s email address?* This field is required.
126
Please select {name5:first}'s race* This field is required.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Prefer not to answer
127
Please select {name5:first}'s ethnicity* This field is required.
Hispanic or Latino
Not Hispanic or Latino
Prefer not ot answer
128
What is {name5:first}'s preferred language?* This field is required.
129
Who will be listed as the primary contact on the account?* This field is required.This person will be contacted first and will receive the appointment reminders and pre-check-in notification.
First Name
Last Name
Please Select
Please Select
Mother
Father
Grandmother
Grandfather
Step-Mother
Step-Father
Aunt
Uncle
Foster Mother
Foster Father
What is the relationship to the patient(s)
130
Should {guardian1[1]} be listed as the responsible billing party on this account?* This field is required.The account holder responsible for billing will receive notifications and statements regarding billing matters
YESNO
131
Responsible Billing Party

If the primary account holder is not listed as the responsible billing party, a second parent or guardian is expected to be added to the account to take on that role.
132
What is {guardian1[1]}'s home address?* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
133
What is {guardian1[1]}'s email address?* This field is required.
example@example.com
134
What is {guardian1[1]}'s phone number?* This field is required.We prefer a cell number when possible
135
Can {guardian1[1]} receive text messages at this number?* This field is required.
YESNO
136
When creating your patient portal account, do you want it set up using your cell number or email address as your login?* This field is required.
Cell NumberEmail Address
137
Is there another parent or guardian you want listed on the account?* This field is required.
YESNO
138
Who is the second contact on the account?* This field is required.
First Name
Last Name
Please Select
Please Select
Mother
Father
Grandmother
Grandfather
Step-Mother
Step-Father
Aunt
Uncle
Foster Mother
Foster Father
What is the relationship to the patient(s)
139
Does {guardian2[1]} reside at the same address as {guardian1[1]}?* This field is required.
YESNO
140
What is {guardian2[1]}'s home address?* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
141
What is {guardian2[1]}'s email address?* This field is required.
example@example.com
142
What is {guardian2[1]}'s phone number?* This field is required.We prefer a cell number when possible
143
Can {guardian2[1]} receive text messages at this number?* This field is required.
YESNO
144
Should a patient portal account be created for {guardian2[1]}?* This field is required.
YESNO
145
When creating the patient portal account, do you want it set up using the cell number or email address as its login?* This field is required.
Cell NumberEmail Address
146
Should {guardian2[1]}'s portal access include billing information?* This field is required.
YESNO
147
How did you hear about Peak Pediatric Care?* This field is required.
Searched Google
Referred by Insurance
Facebook Advertisement
Nextdoor Advertisement
Mentioned on Social Media
Recommended by Friend/Family
Other
148
Do you have anything additional you want to include with your registration?This can include any questions you have or information you’d like us to know.
149
🛑 To register your family as patients at Peak Pediatric Care, you must agree to our vaccine, appointment, and billing policies. It looks like you selected “No” for one or more of these policies. If you’d like to continue with registration, please go back, review, and agree to all policies.
150
🛑 Sorry, we do not currently accept your insurance

Unfortunately, we are not currently accepting new patients with MassHealth, Wellsense, or any other Medicaid plan as their primary insurance. We hope to reopen to Medicaid in the future, but we do not currently have a timeline for when that would be.

If you are already registered at Peak and want to transfer another child to our practice, please call our office at (508) 576-5010 for assistance.
Should be Empty: