Pediatric Appointment Request

Pediatric Appointment Request

Need care for your child today? You’re in the right place. Little Steps Pediatric House Calls provides pediatric visits in your home or virtually. Complete this short form to request an appointment. Full intake will be sent after booking.
Go to the ER now if your child has trouble breathing, is hard to wake, has severe pain, bluish lips or face, or signs of dehydration.
Parent/Guardian Full Name*
Best Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Child’s Full Name*
Child’s Date of Birth*

MonthDayYear
Date
In-Home Sick VisitVirtual VisitSchool or Sports Physical
Yes, MedicaidYes, Insurance not MedicaidNo, Self-Pay
Insurance Company
Select your preferred appointment time*
Briefly, what is going on with your child?
Secure Your Appointment

To reserve your child’s visit, payment may be required at booking.

Self-pay visits:
Full payment is required to confirm your appointment.

Insurance visits other than Medicaid:
A 50 dollar reservation fee is required to hold your appointment. This fee is applied to your visit balance or retained if the appointment is missed or canceled late.

Medicaid visits:
No payment is required at booking.

Your appointment is not confirmed until payment is completed, if payment applies.
I understand and agree: This is a request and not a guaranteed appointment. My visit will be confirmed after review. My appointment is not reserved until payment is submitted, if payment is required. For insurance visits, a $50 reservation fee is required and will be applied to my visit balance or retained if the appointment is missed or canceled with less than 24 hours’ notice. Insurance coverage is not guaranteed. I am responsible for any remaining balance not covered by insurance. Self-pay visits require full payment at booking. This service is for non-emergency care. If my child has severe or worsening symptoms, I will seek urgent or emergency care. I consent to evaluation and treatment of my child by a licensed healthcare provider. I will complete the required intake form prior to the visit to avoid delays or cancellation. I understand telehealth visits have limitations and may require in-person follow-up if clinically indicated.*

I agree
I agree
Insurance eligibility will be verified after booking. If your insurance is not accepted, you will have the option to continue as self-pay or receive a refund
Choose the option that applies to your visit:

Medicaid patients → select Medicaid Visit
Insurance patients → select Reservation Fee
Self-pay → select full visit payment
I understand and agree that my appointment time is reserved specifically for my child. I acknowledge that cancellation or no-show fees may be charged to my card on file in accordance with the policy above. I understand that my appointment is not confirmed until reviewed and approved, and payment must be completed when applicable to reserve my visit.

My Products

Medicaid Visit — $0 (Only choose if you have Medicaid)

Eligibility will be verified prior to your visit.

$ Free

Insurance Reservation Fee — $50 (Required to hold appointment)

This fee secures your appointment and covers administrative review, including insurance verification. Insurance eligibility is not guaranteed. If your plan is not accepted, you may choose to continue as self-pay or receive a refund.

$50.00

Self Pay Option: In-Home Sick Visit — $150

Full payment for self-pay sick visits.

$150.00

Self Pay Option: Virtual Visit — $45

$45.00

Self Pay Option: School /Sports/ Camp Physical — $50

Full payment for self-pay physical.

$50.00

Total

$0.00

Credit Card

Should be Empty: