New Patient Registration | Health and Healing Pediatrics

Parent first name

Parent last name

Parent date of birth

Parent relation to child

Email address

Phone number

Street address

City

State

ZIP code

Country

Child first name

Child last name

Child date of birth

Child gender

Do you have insurance?

Subscriber's full name

Subscriber's date of birth

Commercial insurance name

Commercial insurance member ID

Commercial insurance address

Medicaid plan

Medicaid ID

Choose your preferred clinic to visit

Any questions?

Please print the form, fill it up and bring it to your appointment, or email the completed form to info@healthandhealingpediatrics

I agree to receive calls, texts, or emails from Health and Healing Pediatrics.

I confirm I’ve downloaded the Medical Release Form.

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New patient registration form