New Patient Intake Form

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

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 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 Dr. Hayford must be already assigned by Medicaid. We are NOT able to accept any new patients other than those with MHS and assigned to Dr. Hayford at this time.

          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 CONTACT US
                  • 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...