New Patient Intake Form

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

Please correct the errors described below.

If child has Indiana Medicaid, they must already be assigned to Dr. Hayford as a patient to establish care. If you are unsure, 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 their past medical history.

***NOTE: Please watch for a return email from our office. We will contact you via email for additional information and/or when your child has been pre-registered and ready for you to call and schedule a new patient visit.***

Child's Name

Parent or Guardian Information

Medical History

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

          Medical coverage under Medicaid

          IF your child has Medicaid, they must have (MHS) MANAGED HEALTH SERVICE and list Dr. Hayford as your child's Medicaid physician to establish care here in our office.

          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
                  • You may always reach us by using our secure link at www.indypeds.com using the SECURE FROM-CONTACT
                  • A member of our staff will be in contact with you tomorrow or the next business day. Please watch your email. Thank you.

                  Your information will be encrypted.

                  Loading...