Patient Appointment and Registration Form

Sick/Concern/Follow-up

Please fill this form for an appointment request/confirmation
Welcome. Is this your first visit?*

YesNo
You MAY NEED to complete the Authorization for Release of Medical Records form for Omega Pediatrics. A link to this form will be emailed to you after your submission or you may access it from our website homepage
You MAY NOT NEED to complete the Authorization for Release of Medical Records to Omega Pediatrics if previously filled
Caregiver/Parent's Name*

First NameLast Name
Preferred Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
The next section is to get a little bit more information so that the visit can go as fast as possible. This will save you time.

Additional Questions
Type of insurance/How we pay*

PrivatePublicNo insurance (Cash/Credit/Debit)
Name of accepted public insurance company*
Name of accepted Private insurance company*
Upload the front of your Insurance card here (upload photo ID if insurance card not yet available)*
Upload the back of your Insurance card here (upload photo ID if insurance card not yet available)*
Upload if you ONLY have insurance card photo

Cancelof
Primary Policy Holder's Name (Parent's name if no insurance)*
Primary Policy Holder's gender*

MaleFemaleOther
Primary Policy Holder's date of birth (Parent's DOB if no insurance)*

DayMonthYear
Date
Policy number (type zeros if paying out-of pocket and no insurance)*
Primary Policy Holder's address (Parent's address if no insurance)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Sick/Concern/Follow-up