New Patient Intake Form

Please call office for a newborn appointment. We are accepting new patients and are in network for most commercial payers. If your child is on Indiana Medicaid, we are in network with Managed Health Services (MHS) and you must already be assigned to Dr. Hayford's Medicaid panel to establish care.

Please correct the errors described below.

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

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          Insurance Information #1 (NOT MEDICIAD)

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              Insurance Information #2 (NOT MEDICAID)

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                  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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