Infant Toddler New Patient Form for Children 0-3 years Please enable JavaScript in your browser to complete this form.Baby's Name *FirstLastBaby's DOB *Best Contact Email *Best Contact Phone *Patient Mailing Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeParent/Guardian InformationGuardian 1 Relationship to Patient *Guardian 1 Email *Guardian 1 Phone *Parent/Guardian 2 NameFirstLastParent/Guardian 1 Name *FirstLastGuardian 2 Relationship to PatientGuardian 2 EmailGuardian 2 PhonePatient InformationExpected Due Date *# Weeks/days Premature *Describe Pregnancy *Describe Birth *Hospitalization at Birth? *YesNoIf yes, how many days?Describe HospitalizationHealth History *Feeding History *(breast, bottle , type of bottle, type of milk etc.)NG or g tube fed? *YesNoIf yes, how long?G-tube schedule/rate:Surgeries *YesNoPlease describe surgeriesLab or Pending Lab Results? *YesNoLab DetailsCURRENT Medications *CURRENT Feeding Method *CURRENT Sleeping *CURRENT Caregiver Situation *(home, daycare etc.)What is Most Difficult for My Baby *What is Most Difficult for Me Caring for My Baby *Family Goals for Baby *My baby's team includes (please provide name and contact details)Pediatrician:Physician Specialist(s):Family Outreach Coordinator:Speech Therapist:Physical Therapist:Lactation:Daycare:Responsible Party/Insured InformationResponsible Party's Name *FirstLastResponsible Party's Relationship to Patient *Responsible Party's Address *Street, City, State, Zip CodeResponsible Party's Cell Phone Number *Responsible Party's Email Address *Responsible Party's Date of Birth *Insurance InformationPayment will be via:CashPrivate InsurancePrivate Insurance (additional)Medicaid PrimaryPlease check all that apply and fill out the appropriate sections belowPrimary Insurance NamePrimary Insurance Policy #Secondary Insurance Name Secondary Insurance Policy #Upload a Copy of Your Insurance Card Drag & Drop Files, Choose Files to Upload You can upload up to 2 files. Please provide a copy of both sides of your insurance card for our records. JPG or PNG files allowedPatient ConsentThe patient authorizes to disclose all or any part of the patient’s medical or financial records to any person or entity which is or may be liable under contract to this clinic, to the patient, or to a family member or employer of the patient to pay all or a portion of the cost of care provided to the patient, including but not limited to, hospital or medical service companies, health care companies, insurance companies, worker’s compensation carriers, welfare funds, or the patient’s employer or the clinic’s auditors. All information obtained will be kept private and used only for the planning of services or for billing for services provided from Pediatric Potentials. List all service providers that may be contacted by Pediatric Potentials for records, medical information (e.g. physicians, schools, other therapy providers, hospitals, etc.)Provider 1Please provide provider's name, address, phone#, and information type hereProvider 2Please provide provider's name, address, phone#, and information type hereProvider 3Please provide provider's name, address, phone#, and information type hereProvider 4Please provide provider's name, address, phone#, and information type hereProvider 5Please provide provider's name, address, phone#, and information type hereAgreement *My typed name below equals my signing this consent to release medical information agreementName *Date *Thank you for providing this information to Pediatric Potentials. We will review the information and look forward to seeing you at your appointment. At that time we will request signatures or additional information as needed. Submit
