New Patient Forms

The following set of four 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.

Patient Information:

Family History:

Consent to Treat:

Financial Policy:

All forms must be completed and we must have your child's records from his/her previous provider before an appointment can be scheduled. 

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)

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.

Enola Office • 1824 Good Hope Road, Suite 201 (717) 791-2680
Camp Hill Office • 25 West Shore Drive (717) 791-2680