New Patient Registration

Complete the form below and submit online — our team will contact you to schedule your first visit.

Back to New Patients

American Pediatrics

Office Location *

Today's Date

Patient Information

Click here if you are an expecting parent

Expected Due Date *

OBGYN

Patient's Full Name *

DOB *

Sex *

Address *

City *

State *

Zip *

Parent / Guardian

Parent/Guardian Name *

DOB

Relation *

Occupation

Work Phone

Cell Phone *

Email *

Parent / Guardian #2

Parent/Guardian Name

DOB

Relation

Occupation

Work Phone

Cell Phone

Emergency Contact

Emergency Contact *

Relation *

Phone *

Siblings

Sibling Name

DOB

Insurance Information

Insurance Company *

Type

Primary Subscriber *

DOB

Member # *

Group #

Relation

How Did You Hear About Us? *

Important: Due to recent changes in insurance policies, please add your baby to the insurance plan on the day your child is born to ensure coverage from day one.

Please complete all required fields (marked with *) before submitting.

Please provide an Emergency Contact Name other than a Parent or Guardian who can be reached during emergencies.

Please provide an Emergency Contact Phone other than a Parent or Guardian who can be reached during emergencies.

Draft saved

💬 Chat with Our Team

Tell us a bit about yourself so we can help you faster

Your Name *

Please enter your name

Phone Number *

Please enter a valid 10-digit phone number

Email Address *

Please enter a valid email address

Which Location? *

Please select a location

How can we help? *

Please select how we can help you

← Go back to the AI assistant