Appointment Disclosures

Is this a medical emergency?*

Yes
No

STOP using this scheduler and dial 911 if you have any emergency such as chest pains, uncontrolled bleeding, poisoning, constant vomiting, serious breathing problems, or anything else you deem as life or limb threatening. Pediatric People's online scheduler is not for emergency treatment.

Fee for Missed Appointment*

I understand that I will be charged $75 if I miss an appointment.

Is the patient current on ALL immunizations.*

Yes
No

If your child is older than 12 months, you certify that they received the MMR vaccination*

Yes
No

The safety of our patients and employees is important to us. Therefore, we ONLY treat patients who are current on their immunizations.

What best describes the visit you are scheduling?*
Sick or Urgent Care (fever, cough, fracture, headache, burn, laceration, etc.)
Behavioral Care (ADD, ADHD, mental health, etc.)
Annual Well Care
Ear Piercing
Flu Shot

ALERT!
Since FluMist was deemed ineffective and was not approved for use by the Centers for Disease Control and Prevention (CDC), insurance companies will not provide coverage, so Pediatric People will not be offering it during this flu season.

Do we have the patient's complete immunization records?*
Yes
No

Before scheduling this visit, we must have the patient's complete immunization record. If you need more information, please contact us at 214-396-5200.

If you need to request medical records from a previous physician, click here.

Disclosure of ALL Symptoms/Concerns*
I understand that the doctor will ONLY discuss the symptoms/concerns that I've listed (on the next page) when scheduling this appointment. I understand that additional symptoms/concerns not disclosed will require an additional visit.

Disclosure of ALL Concerns*
I understand that the doctor will ONLY discuss the concerns that I've listed (on the next page) when scheduling this appointment. I understand that additional concerns not disclosed will require an additional visit.

APPOINTMENT SCHEDULER