New Patient Pre-Registration
New and prospective patients, please complete the pre-registration process to enroll in our practice. Please do not fill the pre-registration if you are already a patient in our practice.
Forms
New Patient Forms
- New Patient Demographics
- Consent for Disclosure
- TB Risk Assessment
- Medical Record Release - For New Patients of Dekalb Pediatric Associates
- Medical Record Release - For Patients Leaving Dekalb Pediatric Associates
- 2023 Office Policy
- HIPAA Notice of Privacy Practices
Allergy Test Forms
Vaccine Forms
Before your child's scheduled well visit, please complete and sign the appropriate online form below.
- 2 Months Old
- 4 Months Old
- 6 Months Old
- 12 Months Old
- 15 Months Old
- 18 Months Old
- 24 Months Old
- 30 Months Old
- 4 Years Old
- 11 Years Old - TDAP, MCV, HPV
- 11 Years Old - 2nd HPV
- 16 Years Old
- 17 Years Old - Bexero
- 17 Years Old - 2nd Bexero
Form Completion Form
Payment & Insurance
Payment is requested upon time of service. We accept Cash, Debit, Visa and Mastercard. For self-pay patients, payment plans can be arranged. Contact the office and discuss your needs with our Billing Manager.
