Skip to content
214.396.5200 | 11955 DALLAS PKWY, FRISCO | M-F 8-6 SAT 9-12 SUN 3-5
LOG-IN
Schedule Appointment
Existing User Log-in
Forgot Password
Forgot Username
MAKE A PAYMENT
MESSAGE
E-VISIT CHECK-IN
APPOINTMENTS
NEW PATIENTS
Medical Record Release
Registration Documents
Prenatal / New Parents
LEARN MORE
Accepted Insurance
Covid-19
Ear Piercing
Hospital Affiliations
Locate / Contact
Medication Dosage
Meet Our Providers
Medical Services
Pediatric Careers
Referrals
Resources
APPOINTMENTS
NEW PATIENTS
Registration Documents
Medical Record Release
Prenatal/New Parents
LEARN MORE
Accepted Insurance
Pediatric Careers
Ear Piercing
Hospital Affiliations
Locate / Contact
Medication Dosage
Meet Our Providers
Medical Services
Payment
Referrals
Resources
LOG-IN
Schedule Appointment
Existing User Log-in
Forgot Password
Forgot Username
MESSAGE
APPOINTMENTS
NEW PATIENTS
Medical Record Release
Registration Documents
Prenatal / New Parents
LEARN MORE
Accepted Insurance
Covid-19
Ear Piercing
Hospital Affiliations
Locate / Contact
Medication Dosage
Meet Our Providers
Medical Services
Pediatric Careers
Referrals
Resources
Search for:
NEW PATIENT REGISTRATION
Registration Documents
Michael
2017-01-23T11:46:48-06:00
Step 1 of 12 - PATIENT INFORMATION
0%
How many children are you registering?
*
1
2
3
4
5
6
PATIENT 1
Patient 1 Name
*
First
Last
Patient 1 Date of Birth
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Patient 1 Gender
*
Female
Male
PATIENT 2
Patient 2 Name
*
First
Last
Patient 2 Date of Birth
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Patient 2 Gender
*
Female
Male
PATIENT 3
Patient 3 Name
*
First
Last
Patient 3 Date of Birth
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Patient 3 Gender
*
Female
Male
PATIENT 4
Patient 4 Name
*
First
Last
Patient 4 Date of Birth
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Patient 4 Gender
*
Female
Male
PATIENT 5
Patient 5 Name
*
First
Last
Patient 5 Date of Birth
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Patient 5 Gender
*
Female
Male
PATIENT 6
Patient 6 Name
*
First
Last
Patient 6 Date of Birth
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Patient 6 Gender
*
Female
Male
Mailing Address
*
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Consent for Medical Treatment
*
There are no court orders now in effect that prohibits me from signing this consent. I do hereby request and authorize the doctor(s) and practice staff of Pediatric People PLLC to perform ALL necessary medical care for my child(ren). I understand that all medical treatments contain inherent risks.
Will you allow anyone, other than a legal guardian, to bring your child(ren) to Pediatric People, PLLC for treatment?
*
Yes, I do authorize and consent to Pediatric People PLLC to provide medical treatment to my child without my presence.
No, the above mentioned child(ren) will be accompanied to the office by their parents or legal guardian for all medical treatment.
Authorized Individuals
*
First Name
Last Name
Financial Policy
*
I understand that insurance co-payments, deductible, self-payment or outstanding balances are due
BEFORE
my child’s visit.
We may refuse service if you have an unpaid balance.
Assignment of Benefits
*
I hereby assign to Pediatric People PLLC all insurance benefits, if any, otherwise payable to me for services rendered to myself and/or my dependent(s), and I hereby authorize and direct my insurance carrier to issue payment of such benefits directly to Pediatric People, PLLC. I authorize the use of my signature, and a copy thereof, on the insurance submissions.
Charges for Medical Services
*
I understand some services may not be covered by my insurance or may be applied to my deductible.
I agree to pay all charges, in full, once they have been processed by my insurance company, if any balance remains due. Below are the most common procedures and tests that may be applied toward your insurance deductible. These costs are approximate and will vary based on your insurance company. These charges are in addition to the office visit charge.
- Earwax Removal $65 - $75
- Lesion/Wart Destruction $125 - $175
- Sutures, Staples or Skin Glue $125 - $225
- Abscess Care $150 - $180
- X-rays & Radiologist $25 - $39
- Splinting $50 - $95
- Breathing Capacity Test $19
- Flu Test A $15
- Flu Test B $15
- Strep Test $15
- RSV Test $9
- Mono Test $7
Communication
*
I authorize Pediatric People, PLLC to communicate with me via the methods below. I understand that this authorization allows Pediatric People, PLLC to leave a message or send an email regarding test results, appointments, referrals, or other information regarding your child’s care.
By Phone:
*
Phone Number (000-000-0000)
Can we leave a voice mail?
*
Yes
No
Email
*
Enter Email
Confirm Email
Notice of Privacy Practices
*
I have reviewed Pediatric People PLLC's Notice of Privacy Practices dated October 1, 2013. I understand that I may receive a printed copy of this notice upon verbal or written request now or in the future. The notice may also be viewed on our website at PediatricPeople.com.
Immunization Certification
*
Yes, I immunize my child according to the immunization schedule established by the Centers for Disease Control and Prevention. I certify that my child is current with ALL immunizations.
No, I do NOT immunize my child according to the immunization schedule established by the Centers for Disease Control and Prevention.
STOP!
Non-immunized individuals pose an extreme health risk to newborn children because newborns are unable to receive immunizations until 2 months of age. Please ask for assistance.
Authorization Code Required
*
Please see a reception desk employee to obtain an authorization code.
Missed Appointments
*
I understand that I will be charged
$75
if I fail to cancel an appointment before the scheduled time.
Arriving Late
*
I understand that if I arrive more than
10 MINUTES
late, my appointment
WILL
be rescheduled.
Portal Secure Messaging
*
I understand that this service is NOT for medical situations requiring an immediate response. I can expect up to a 48-hour response time.
After-hours Nurse Line
*
I understand to use the after hours nurse telephone service is
$17
per call.
Transaction Recordings
*
I understand that Pediatric People PLLC records
ALL
inbound and outbound telephone calls, including verbal conversations within
ALL
Pediatric People facilities.
Form Completion Without a Visit
*
I understand that I may be charged a fee to have a provider complete a form.
My physician will complete forms and prescription refills during my visit at no charge. All forms requiring medical review and a physician's signature without a visit, will incur the following charges:
- FMLA, Disability or Complex Forms - $29
- Asthma Action Plans - $19
- Allergy Plans - $19
- Sports Physical Forms - $19
- Day Care/School Attendance Forms - $9
Card Type
*
Visa, MasterCard or Discover
American Express
Cardholder Name
*
First
Last
Credit Card Number
*
Credit Card Number
*
Credit Card Expiration Date
*
Required Credit Card On File
*
I understand that I must keep a valid credit card on file.
I authorize Pediatric People PLLC to charge my credit card for any amount not covered by my insurance company.
Once your insurance claim is final, we will automatically charge your card for any outstanding balance. You will receive an email receipt with details regarding the charge.
CCOF Authorization
I, the Cardholder, do hereby authorize Pediatric People PLLC to charge my credit card all charges not covered by my insurance company. This agreement shall remain in effect until the specific credit card expires, or until revoked by written notification from me, or at the discretion of Pediatric People PLLC.
Signature of Cardholder
*
Portal Password
*
(Must be between 8-20 characters.)
Confirm Portal Password
*
Choose a portal security question.
*
What was your dream job as a child?
What was the name of your favorite food as a child?
What was your favorite childhood pet's name?
What was your best friend's name when you were a child?
What is your all-time favorite past-time?
Portal Security Answer
*
Mother's (or Legal Guardian's) Name
*
First
Last
Father's (or Legal Guardian's) Name
*
First
Last
Signature of Legal Guardian
*
How did you hear about us?
*
Word-of-mouth
Sibling of Current Patient
Internet
Direct Mail
Drive-by
Insurance Website
Internet Search
Referred by Physician
YELP
Facebook
Other
IP Address
Toggle Sliding Bar Area
RESOURCES
Medication Dosage Info
Well Child Exam Schedule
Basic Car Seat Safety
QUICK FIND
Schedule Appointment
Services
Resources
FORMS
New Patient Registration
Medical Record Release
PATIENT PORTAL
Log-in
Forgot Password
Forgot Username
