New Patient Intake Form

New Patient Intake

Please call the office for a newborn appointment or your baby is just being discharged from the hospital. Please get in touch with the office at 317-293-7177 and press option 1.

Child's Name

First name

Last name

Date of Birth

Gender

Male

Female

Street Address

City

Zip Code

Parent or Guardian Information

First name

Last name

Primary Phone Number

Relationship to child

Email address

Medical History

Has the child been treated by a doctor in the last 12 months?

Yes No

If yes, please describe the reason for the visit

VACCINE RECORD

Yes- I have vaccine and lead record -Take a photo and UPLOAD vaccine and lead record below No - If you are coming from out-of-state, please request the vaccine record. Registration will be pending until the records are received.

Vaccine Record Photo If you are not able to upload here, please fax to 317-293-3991, or drop off to our office.

Add file

Please upload a file

Vaccine Record - If more than 1 page

Add file

Please upload a file

Does your child have Medicaid? Medicaid ID number needed for pre-registration, if yes.

Yes No

Medicaid ID Number:

Does your child have other insurance (NOT Medicaid) Take a photo, front and back of card and upload below.

Yes No

Insurance card copy - FRONT

Add file

Please upload a file

Insurance card copy - BACK

Add file

Please upload a file

Name of Insurance Company

Member ID number

Please upload a copy of insurance card above OR provide mailing address listed on the back of card.

Subscriber Name

Subscriber DOB:

Subscriber Address - including City, State, Zip:

If more than 2 commercial insurance (Not MEDICAID) Take a PHOTO & Upload

Insurance card copy - FRONT

Add file

Please upload a file

Insurance card copy - BACK

Add file

Please upload a file

Name of Insurance Company

Member ID Number:

Please upload a copy of insurance card above OR provide mailing address listed on the back of card.

Subscriber Name:

Subscriber DOB:

Subscriber Address- including City, State, Zip:

A member of our staff will be in contact with you tomorrow or the next business day. An email will be sent when registration has been completed OR if additional information is required to complete. Thank you.

Your information will be encrypted.

New Patient Intake Form

Parent or Guardian Information

Medical History

A member of our staff will be in contact with you tomorrow or the next business day. An email will be sent when registration has been completed OR if additional information is required to complete. Thank you.