TV Kids Clinic Registration

Welcome!

We are excited to have your family join us. Please review our policies, complete the registration and sign up for Quick Pay!
Insurance Carrier(s)*
Please verify with your insurance company that we are in-network prior to your first appointment
Other (please specify)
We are attempting to contract and credential with all major insurers. Please contact us if your insurer is not listed above.

Clinic Policies

We know everyone hates rules--especially toddlers and teens! Our goal is to build a long-lasting relationship with your family, and understanding our policies is key to setting appropriate expectations and ensuring a smooth experience for all.
Key Policy Reminders

Our goal is to build a partnership with our patients in their care. In order to do so we simply ask that you abide by three simple rules:

1. Be courteous and respectful to each other and our staff. We have a zero-tolerance policy for misbehavior and abuse.
2. Be on time and ready for your appointment. We understand that emergencies arise (both on your part as well as ours). Please cancel any appointment you cannot make at least 24 hours in advance.
3. Be vaccinated. We follow the AAP Bright Futures and ACME vaccination schedule. We strive to help educate and overcome any vaccine hesitancy. While we do not mandate the flu, COVID-19 and HPV vaccines, we highly encourage our patients getting them. We only allow for alternative or customized vaccine schedules on a case by case basis after discussion with a provider. We require patients who transfer into our practice and are behind on their vaccine schedule to agree to a catch-up schedule to become patients with us.
Please review the attached policies and acknowledge below (a copy of this will be emailed to you following submission)

Primary Care Provider Preference

We are excited to have an excellent team to help care for your family. All providers are excellently trained and follow the same philosophy and standards of care. Some patients/families may prefer a specific gender for their PCP. As best as able we aim to accommodate your choice below.
PCP Gender Preference*

MaleFemaleNo Preference

Medical Issues and Concerns

In order to provide the best care, please list below any chronic medical conditions (i.e. medical issues that require ongoing medications or visits to specialists) and/or significant concerns (i.e. growth and development, behavior, etc.).

Parent or Guardian Information

Parent/Guardian #1
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Hey there! Can you give us your cell phone number so we can keep you in the loop with important office updates and appointment reminders? It'll make things a lot easier for everyone!
Email Address (for patient portal)*
example@example.com
Parent's Preferred Language*
Relationship to Child*

MotherFatherStepmotherStepfatherGrandmotherGrandfatherOther

Parent or Guardian Information (Optional)

Parent/Guardian #2
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Hey there! Can you give us your cell phone number so we can keep you in the loop with important office updates and appointment reminders? It'll make things a lot easier for everyone!
Email Address (for patient portal account)
example@example.com
Parent #2 Preferred Language
Relationship to Child

MotherFatherStepmotherStepfatherGrandmotherGrandfatherOther

Welcome!