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.

Pre-Register Now

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

• Allergy Questionnaire
• Allergy Consent 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

• Form Completion Request

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.

Insurance Accepted