New Patient Intake Form

Please call our office if you are calling for a newborn appointment.

Please correct the errors described below.

If you child has Indiana Medicaid, they must already be assigned to Dr. Hayford as a patient to establish care. If you are unsure, please go ahead and complete the form and someone will research and respond. Please make sure you include below the Medicaid ID number located on the Medicaid card.

The first appointment scheduled will be a new patient comprehensive examination. It is designed to include a thorough review of your past medical history.

Child's Name

Parent or Guardian Information

Medical History

    Please upload a file
      Please upload a file
        Please upload a file

        Medical coverage under Medicaid

        Insurance Information #1 (NOT MEDICIAD) Take a PHOTO and Upload

          Please upload a file
            Please upload a file

            Insurance Information #2 (NOT MEDICAID) Take a PHOTO and Upload

              Please upload a file
                Please upload a file

                A member of our staff will be in contact with tomorrow or the next business day in the office. Thank you.

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