New patient registration form

New Patient Registration Form

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

Skip the fields that are not applicable.

Commercial insurance name

Commercial insurance member ID

Commercial insurance address

Medicaid plan

Medicaid ID

Choose your preferred clinic to visit

Any questions?

Click here to download the Medical Record Release Form

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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Your child’s happiness means everything to us.

We understand that every child is unique, and their health and happiness are at the heart of what we do. Register now and let us take care of your child’s health with our dedicated pediatricians.

New patient registration form

Skip the fields that are not applicable.

Click here to download the Medical Record Release Form

Your child’s happiness means everything to us.

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