Pediatric New Patient Intake Form
Welcome to the pediatric new patient form. Please fill out this form as completely as possible. If you need help answering a question, leave it blank if it is NOT a required field, or call us at 813 926-9500. We will help you answer the necessary unanswered questions when you arrive at the office.
Completing this form online will speed up your initial visit. It will take 5-10 minutes to complete this form. Most insurance companies will not cover pediatric treatments unless a specific condition exists. Choose the cash option to bypass the insurance questions. Please speak with the doctor regarding insurance eligibility for pediatric adjustments.
The form can be completed on a mobile phone, but it is easier on a tablet or desktop. All fields with an asterisk are required fields.