• Welcome to Vero Beach Pediatrics — Let's get your child registered.

    We're so glad you're considering us for your child's care. Just a few quick questions to get your family set up — it only takes about a minute.
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  • Secondary Parent/Guardian Date of Birth
     - -
  • Does the secondary parent/guardian live with the patient?
  • Format: (000) 000-0000.

  • About Your Child

    Tell us about the child you'd like to register. You can add additional children later in the form.
  • Child's Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Would you like to register an additional child?
  • Child 2 Date of Birth
     - -
  • Is the address and emergency contact the same as Child 1?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Would you like to register a third child?
  • Child 3 Date of Birth
     - -
  • Is the address and emergency contact the same as Child 1?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Would you like to register a fourth child?
  • Is the address and emergency contact the same as Child 1?
  • Child 4 Date of Birth
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Primary Parent/Guardian Information

  • Parent/Guardian Date of Birth*
     - -
  • Does this parent/guardian live with the patient?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Would you like to add a second parent/guardian to your child's record?
    • Secondary Parent/Guardian 
    • Format: (000) 000-0000.

  • Primary Insurance

    Tell us about the insurance plan that will cover your child's care.
  • Subscriber's Date of Birth*
     - -

  • Authorized Persons

    List anyone other than the parent or guardian who is allowed to bring your child to appointments. These persons must bring photo ID at every visit.
  • Should be Empty: