Online Forms

For your convenience we have placed our forms online. Save time by filling out your new patient forms online now. Once completed the forms can be faxed to us or simply bring them your child’s New Patient appointment.

Follow just a few simple steps and SAVE time  1-fill out the forms, 2-print them or email them  and 3-bring the forms with you to your child’s New Patient appointment. or you may fax us your completed forms at least 3 business days prior to the appointment.

Directions to email:  forms@merchantpediatrics.com attach filled out forms.

Please include the following in the subject line and in the body of your email:

  1. Appointment Date
  2. Office Location where appointment is scheduled (Hunter’s Creek, Kissimmee (Loop) or Dr. Phillips)

The following to be included in the body of the email

  1. Name of your child
  2. Child’s Date of Birth (DOB)
  3. A good contact phone #
  4. Your name
  5. Your relationship to child

Example: If your child’s name is Jane Moe, born May 7, 2010 and her appointment is at our Dr Phillip’s location on June 9, 2014 at 2:00 p.m.

Subject line and body of your email: 6/9/14 Dr Phillips office

The email itself would say only: Jane Moe – DOB 5/7/10    (407)555-4747      Sue Moe, Mother

Then attach the forms….   We will attach the forms to your child’s record and call you if there is anything needed from you.

Immunization records, birth certificates, insurance card copy or any pertinent information will be received the day of the appointment please do not send this prior to the appointment.

Note: If you are submitting forms for more than one child please send them in separate emails, one per child.

To view and print our forms, you will need the Free Adobe Acrobat Reader ® software. You may download Adobe Reader for free at http://www.adobe.com/reader.

get_adobe_reader

 

New Patient Registration Forms

New Patient Registration Form Ages 0 – 17  download-icon DONELOAD

New Patient Registration Form Ages 18 -21 download-icon DONELOAD

Individual Forms

Medical Records Release Form download-icon DONELOAD

 

 

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