TV Kids Clinic Registration

Welcome!

We are excited to have your family join us. Please review our policies and complete the registration
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 are a pro-vaccine, pro-evidence based medicine practice. We follow the AAP Bright Futures and AAP vaccination schedule. We strive to help educate and overcome any vaccine hesitancy and will work with families on an alternative schedule on a case-by-case basis. For those not interested in vaccinating their children at all we may not be the right medical home choice for you.
Vaccination Question:*

We are (or intend to be) up to date on our childhood vaccines (while encouraged, seasonal influenza, COVID and HPV are optional)We have some questions about vaccines and would like to learn moreWe do not plan on vaccinating our child
Please review the attached policies and acknowledge below (a copy of this will be emailed to you following submission)

We are a pro-vaccine, pro-evidence based practice. For the overall safety of all our patients (such as those too young or immunocompromised and cannot to be fully vaccinated) we have specific protocols in place for any child that is not fully up to date on their vaccines. In addition to following specific safety protocols we require comprehensive vaccine counselling and ongoing vaccine counselling at every wellness visit.
I understand the above requirements and would like to proceed with registration (prior to establishing care and scheduling appointments a member of our staff will reach out to discuss in details our safety protocols and vaccine counseling requirements).*

YesNo

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

Insurance Information
Name of Subscriber*

First NameLast Name
Insurance Company Name (as it appears on your card)*
For Medicaid:
Medicaid ID #
Insurance ID (or certificate) #
Group #
Co-Pay Amount Listed on Card:
Date of Birth (of subscriber)

MonthDayYear
Date
Employer
Insurance Card (front and back)

Cancelof
Camera Photo

And lastly...
How did you hear about us?*
Should be Empty:

Welcome!

Clinic Policies

Clinic Registration

Primary Care Provider Preference

Medical Issues and Concerns

Parent or Guardian Information

Parent or Guardian Information (Optional)

Insurance Information

And lastly...