New Patient Registration — Bedford Pediatrics

New Patients

We welcome new patients! To join our practice please either call us or fill out the registration form below. We will need routine contact information and insurance before we can book your first appointment.

Authorization to receive medical records from another practice

Before your first appointment with us, please have any past medical records sent to our office, by mail or fax to 781-275-6212. Records can also be emailed to our secure email address. To request records to be sent to us from a prior provider, please use this request medical records form. We suggest that you follow up with us in a few weeks to ensure we have received your records. If you have hard copies of your records, our New Patient Coordinator will help you upload them through out portal.

We will scan/input the records into our Electronic Medial Record (EMR) and give the record back to you.

There are policies and other information we will have you review and sign at your first visit.

Please complete the registration form below and someone from our office will contact you shortly to complete the registration process. ( Required information “ * ”)

Patient's Name

First Name

Last Name

Patient's Date of Birth

YYYY

Legal Sex

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone Number

(###)

###

####

Patient Cell Phone (if over 13 years)

(###)

###

####

Patient email (if over 13 years)

Needs Interpreter (Yes/No)

Written Language

Ethnicity

Low Vision (Yes/No)

Preferred Language

Form Confidence

Race

Hearing Impaired (yes/no)

Pharmacy Name

Pharmacy address

Parent/Guardian Name

First Name

Last Name

Gender

Parent's Date of Birth

YYYY

Address (if different from above)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home phone

(###)

###

####

Cell phone

(###)

###

####

Parent Email

Relationship to patient

Legal Guardian (Yes/No)

Preferred Language

Interpreter Needed (Yes/No)

Parent/Guardian Name

First Name

Last Name

Gender

Parent's Date of Birth

YYYY

Address (if different from above)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home phone (if different from above)

(###)

###

####

Cell phone

(###)

###

####

Parent email

Relationship to patient

Legal Guardian (Yes/No)

Preferred Language

Interpreter Needed (Yes/No)

Guarantor Name (Person Financially Responsible) Person

Guarantor Date of Birth

YYYY

Insurance Plan Name

Insurance ID #

Subscriber DOB

YYYY

Insurance Subscriber Name

First Name

Last Name

PCP

Message