New Patient – ESD Pediatric Group

Thank you for your interest in becoming patients of ESD Pediatric Group. New patients are accepted after verification of insurance.

Please complete and submit [Prospective New Patient Information Sheet].

Insurance card information: Scan and upload front and back of card

After insurance is verified, you will be contacted by one of our staff with in 24 hours to schedule your child’s first appointment.

ESD Pediatric Group uses digital appointment reminders and check in. Please be sure to complete the digital registration before your child’s appointment.

We look forward to caring for your child from birth through young adulthood.

Should you have any questions, please contact the office at (513) 248-1210.

APPOINTMENTS ARE NOT SCHEDULED UNTIL INSURANCE IS VERIFIED
The practice is not accepting any new Medicaid or Medicaid HMO patients.

PROSPECTIVE NEW PATIENT INFORMATION

First Time Family*
- Yes
- No
If Newborn, Please Indicate*
Newborn Due Date (if applicable)
Sex of Newborn
Mother Delivery Location
Returning Family*
- Yes
- No
Family Last Name*
First
Father*
First Last
Father Date of Birth*
MM slash DD slash YYYY
Mother*
First Last
Mother Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
Location*
Secondary Phone
Location
Email*
Pending Adoption*
If Yes: Caseworker Name
Case Worker #
Name of Children*
DOB*
Name:
DOB
Name:
DOB
Name:
DOB
Name:
DOB
How Did You Hear About Us?*
Reason For Change
Former Provider
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Insurance Information
Patient Name*
Insurance Company Name*
Policy Effective Date*
Policy Owner's Name*
Relationship To Patient*
Policy Holder's DOB*
SSN*
Employer Name*
Group No.*
Policy/ID #*
Co-Pay Amt $ or %*
Insurance Company Phone# Preferably 800#*
Secondary Insurance Information - If Applicable
If Newborn, Please Indicate
Patient Name
Insurance Company Name
Policy Effective Date
Policy Owner's Name
Relationship To Patient
Policy Holder's DOB
SSN
Employer Name
Group No.
Policy/ID #
Co-Pay Amt $ or %
Insurance Company Phone# Preferably 800#
Insurance Card*
Drop files here or

Max. file size: 100 MB.
Digital Signature*

I certify that my child(ren) has/have the commercial insurance coverage(s) referenced above. I understand that my child(ren) is/are being accepted as
new patients with ESD Pediatric Group contingent upon maintaining primary and secondary (if applicable) commercial health insurance which is
currently accepted by the practice for a minimum of twelve (12) months. Should commercial insurance lapse or the child(ren) become(s) ineligible for
coverage during the twelve (12) month period, the patient(s) will receive a written notification of dismissal.

APPOINTMENTS ARE NOT SCHEDULED UNTIL INSURANCE IS VERIFIED The practice is not accepting any new Medicaid or Medicaid HMO patients.

PROSPECTIVE NEW PATIENT INFORMATION

Primary Insurance Information

Secondary Insurance Information - If Applicable

APPOINTMENTS ARE NOT SCHEDULED UNTIL INSURANCE IS VERIFIED
The practice is not accepting any new Medicaid or Medicaid HMO patients.