New Patient Form

Please fill out the information below before we schedule an appointment. (Alternative: printable new patient packet - needs physical signature)

For children to be seen at Cottonwood Pediatrics (Newton, KS)

Preferred Pediatrician

For Newborns: name of the facility where baby was born

Child Name*

First Middle Last

Child Date of Birth*

Legal Gender*

Female
Male

Race

Ethnic Group

Main Phone Number (text reminders and/or calls)*

Social Security Number

Address*

Street Address Address Line 2 City ZIP / Postal Code

Parent Information

Parent 1 Name*

First Middle Last

Parent 1 Date of Birth*

Parent 1 Legal Gender*

Female
Male

Parent 1 Social Security Number *

Parent 1 Place of Employment

Parent 1 Contact Information

Parent 1 phone is different
Parent 1 address is different

Parent 1 Phone

Parent 1 Email

Parent 1 Address

Street Address Address Line 2 City ZIP / Postal Code

Parent 2 Name

First Middle Last

Parent 2 Date of Birth

Parent 2 Legal Gender

Female
Male

Parent 2 Social Security Number

Parent 2 Place of Employment

Parent 2 Email

Parent 2 Contact Information

Parent 2 phone is different
Parent 2 address is different

Parent 2 Phone

Parent 2 Address

Street Address Address Line 2 City ZIP / Postal Code

Insurance Information

Insurance Card - Front

Accepted file types: jpg, jpeg, gif, png, pdf, tiff, Max. file size: 8 MB.

Insurance Card - Back

Accepted file types: jpg, jpeg, gif, png, pdf, tiff, Max. file size: 8 MB.

New Patient Information

Parent Information

Insurance Information

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