Pediatric Practices of Northeastern PA
Providing quality care in Wayne and Pike Counties.
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New Patient Registration Form


Notice of Health Information Practices
This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

New Patient Intake Form
New Patient Demographics Form
New Patient Financial Policy Form
New Patient Consent for Medical Care Form
HIPPA Form
Save yourself time by printing and filling out the above new patient forms which you can then mail to our office or bring with you for your first appointment.

To view the printer friendly version, you must have Acrobat® Reader on your system. If you don't have Acrobat® Reader, please use this link to download the reader.

 


 

 
           

 

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