New Patient Forms
The following set of three online forms are for new patients who have been directed here after speaking to our office staff and have been pre-registered as new patients to our practice.
If you have not contacted our office yet, please call us at 717-791-2680 to register your child. We cannot accept forms submitted without calling our office first.
Please note: Once your first appointment with our practice has been scheduled, please make a note of it. For new patients, a $50 fee will be charged if the FIRST appointment is missed.
When you click on the link below, you will be directed to a page where you will complete three forms:
- Patient Information Form
- Patient Family History
- Consent to Treat
Notes for filling out the forms:
- Please review all information for accuracy before moving to the next form because previously completed forms will not be available for editing.
- All THREE forms must be completed prior to submission.
- Partially completed forms are not saved.
CLICK HERE to complete our online new patient forms.
If you prefer not to complete these forms online, please download the following 2 forms (Patient Family History and Consent to Treat), print, complete, and mail as soon as possible to:
JDC Pediatrics
1824 Good Hope Road, Ste. 201
Enola, PA 17025
All forms, whether submitted online or by mail, must be received in our office before your child's first appointment can be scheduled.
Patient Family History Form
Consent to Treat Form
If you need to request your child’s records from his/her previous provider, you may print and complete the following form, and send it to
your child’s previous provider.
Authorization to Release PHI (Protected Health Information)