New Patient Enrollment

New Patient Enrollment

Enroll your child with Ivy League Pediatrics. We'll email portal access for you to complete registration and schedule your appointment.
Your child
Child first name
Child last name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are you enrolling more than one child?
Additional child details
What brings you to us?
Which practice were you with before?
About the parent or guardian
First name
Last name
Your relationship to the child
Mobile number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Confirm your email address
example@example.com
Where you live
Home address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
How you found us
Most of our families come from someone who told them about us. We'd like to know who to thank.
How did you hear about us?
What's their name?
What's their name?
Which doctor or practice?
Which hospital?
Which one?
Do you remember what you searched for?
Which one?
Roughly when were you last seen?
Tell us where
Your insurance
We're paying ourselves — no insurance to upload
Who is your insurance with?
Front of your insurance card

Cancelof
Back of your insurance card

Cancelof
Photo ID

Cancelof
Before we book you
At your first visit, please bring: your insurance card, photo ID, your child's shot record, and any medications your child takes. If something's missing, come anyway — we'll work it out.
I understand I need to complete my registration and medical history forms before my appointment time, and that Ivy League Pediatrics requires its patients to be vaccinated.
I understand that I'm expected to keep the appointment I schedule. We do not reschedule new patient appointments. If you're not sure about a time, please don't schedule it — tell us on the phone and we'll find one that works.
Signature
By signing, I confirm the information above is accurate to the best of my knowledge, and that I'm the parent or legal guardian authorized to enroll this child.
Sign here
Today's date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

New Patient Enrollment

Your child

About the parent or guardian

Where you live

How you found us

Your insurance

Before we book you

Signature