2-DEMOGRAPHIC FORM

PATIENT DEMOGRAPHIC
Welcome to NxT Step Pediatrics — where kids come first!

We’re so excited that you’re considering NxT Step Pediatrics for your child’s care. Thank you for trusting us with what matters most.

Please complete the following 7 New Patient Forms so we can create your child’s medical chart and begin the scheduling process for your appointment. Once submitted, our team will review your information and reach out to you shortly.

We look forward to partnering with your family on your child’s healthcare journey!
Patient Information
Child 1 Name*
Date of Birth*

MonthDayYear
Child 1
Gender*

MaleFemaleOther
Child 2 Name
Date of Birth

MonthDayYear
Child 2
Gender

MaleFemaleOther
Child 3 Name
Date of Birth

MonthDayYear
Child 3
Gender

MaleFemaleOther
Child 4 Name
Date of Birth

MonthDayYear
Child 4
Gender

MaleFemaleOther
Parent/Guardian Information
Parent 1 Name*
Date of Birth*

MonthDayYear
Parent 1
Address*

Home Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Contact Phone Number*
Format: (000) 000-0000.
Alt. Phone Number*
Format: (000) 000-0000.
Email Address*
example@example.com
Is there another parent or legal guardian involved in your child’s care?*

YesNo
Parent 2 Name*
Date of Birth*

MonthDayYear
Parent 2
Address*

Home Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Contact Phone Number*
Format: (000) 000-0000.
Alt. Phone Number*
Format: (000) 000-0000.
Email Address*
example@example.com
Insurance Information
Do you plan to use insurance for your child’s care?*

NoYes
Photo of Insurance Card (Front)

Cancelof
Photo of Insurance Card (Back)

Cancelof
Primary Insurance*
Ex: Aetna, Cigna, BCBS, etc.
Member ID*
Group #*
Subscriber Name*
Subscriber DOB*

MonthDayYear
Date of Birth
Secondary Insurance
Ex: Aetna, Cigna, BCBS, etc.
Member ID
Group #
Subscriber Name
Subscriber DOB

MonthDayYear
Date of Birth
Pharmacy Information
Pharmacy Name
Pharmacy Address
Pharmacy Phone Number
Format: (000) 000-0000.
Pharmacy Fax Number
Emergency Contact Information
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Phone Number*
Format: (000) 000-0000.
Emergency Contact Alt. Phone Number*
Format: (000) 000-0000.
Parent/Guardian Signature*
Date*

MonthDayYear
Date
How did you hear about NxT Step Pediatrics?

Google SearchInternet AdSocial MediaThrough a friendOther
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PATIENT DEMOGRAPHIC