Pediatric
Registration
To complete this form, you will need the following information and / or documentation:
➞ Patient Demographics (including social security number)
➞ Medical, Dental, and / or Vision Insurance card(s)
➞ Parent or Guardian (demographics | social security number | identification card or driver’s license | authorization for medical treatment of minor, if anyone other than parent with legal custody is completing form)
➞ Tribal identification, if applicable
Please ensure you have all appropriate documents ready prior to completing forms. If your screen is left idle for more than one hour, the system will automatically close, and your forms will not be saved.