Pediatric New Patient Form


What is a pediatric new patient form?

A pediatric new patient form is a document that is used by pedictricians to gather important information about a child’s personal and medical history, the challenges faced, and the health goals. This type of intake form is used for children who visit a facility for the first time to avail medical treatment. This form also includes information of the child’s parents or legal guardians, and is used to ensure that the child receives the best care possible. It provides the healthcare provider with all the necessary information about the child’s existing and past health, to help make informed decisions pertaining to the course of treatment. The form is quite useful in plethora of healthcare settings and is widely used to provide effective care to children. 

Why is a pediatric new patient form important?

A pediatric new patient form is important for a variety of reasons such as: 

  • Gathering all important information about the child’s medical history, including hospitalizations, surgeries, allergies, medications, etc 
  • Identifying potential health risks that the child might be exposed to
  • Streamlining the treatment process, thereby saving the time of both the patient and the healthcare provider 
  • Estabishing trust between the patient and the healthcare provider 
  • Avoiding miscommunications and misunderstandings pertaining to the proposed course of treatment

Who fills a pediatric new patient form?

This form is typically filled by the child’s parent or guardian. Hence it is the responsibility of the person filling out this form to ensure that all the details of the child are clearly mentioned and nothing is left out. Right from the medical history to the insurance details, they need to be accurate while mentioning all the details. This will help the healthcare provider to have a clear understanding of the child’s existing and past medical conditions and develop the most appropriate course of treatment. 

What does a pediatric new patient form include?

The following details are included in a pedicatric new patient form: 

  • Personal information of the child, such as their name, date of birth, gender, etc
  • Details of the parent/guardian, such as their name, relationship with the child, contact information, etc
  • Medical history of the child’s family 
  • Information regarding insurance, including the name of the insurance provider and the policy number 
  • Details of the treatment 
  • Consent of the treatment
  • Signature of the parent/guardian and date of signature 

What things should be taken into consideration while creating a pediatric new patient form?

The legal implications of a pediatric new patient form are as follows:

  • The form must be HIPAA-compliant 
  • The form must include the written consent of the parent/guardian 
  • In case of a legal guardian, all information of the same must be mentioned clearly on the form.