Interlachen Pediatrics Home News & Notes
Who We AreOur MissionOffice InfoMedical InfoContact Us

Office Locations

  • Maitland office
    846 Lake Howell Rd.
    Maitland, FL 32751
    (407) 767-2477
    (407 834-9822 fax
  • Oviedo office
    1000 W. Broadway
    Suite 214
    Oviedo, FL 32765
    (407) 767-2477
    (407) 767-8478 fax

Patient Registration

This form is to be used for new patients to register as patients of Interlachen Pediatrics. New patients wishing to schedule their initial appointment should call the office at 407 767-2477 (Also see link to new patient forms).

Parent/Family Information
Parent or Legal Guardian Name:
Date of Birth:
Relationship to Child:
If other, specify:
Address:
City, State, and Zip:
Home Phone:
Alternate Phone:
Email:
Employer Name:
Social Security Number:
Driver's License #:
# of Dependents:
Patient Information
Patient Name:
Date of Birth:
Patient Name #2 (if applicable):
Date of Birth:
Patient Name #3 (if applicable):
Date of Birth:
Patient Name #4 (if applicable):
Date of Birth:
Patient Name #5 (if applicable):
Date of Birth:
Insurance Information
Company Name:
Policy Number:
Group Number:
Policyholder's Name:
Policyholder's Date Of Birth:
Policyholder's SSN:
Please Review our Privacy Practices
 Please Review our Authorizations & Consent and Financial Policies
By entering your name and date below you certify that you have read, understand and intend to comply with the practices and policies of Interlachen Pediatrics, P.A.
Name:
Date:
Preferred Office Location:
Preferred Physician:
Visit Time Restrictions/Preferences
(afternoon, morning, after 3pm, etc.) :
Reason for Visit:
Please list any ongoing medical issues (e.g. asthma, allergies, ADHD, growth or weight concerns, chronic medicines, etc.) so that the appointment may be scheduled appropriately