New Patient Packet — Pediatric

For new patients under 18, a parent or legal guardian completes this packet. It covers the same ground as the adult version and adds the sections a pediatric chart needs. It is a fillable PDF — type it, save it, and bring or email it ahead of the first visit.

What’s in the packet

Patient Information — the child’s name, date of birth, address, race, ethnicity and preferred language; a patient phone and email if the child is 17 or older.
Parents / legal guardians — contact details and relationship for up to two guardians, and, if the parents are divorced or separated, who the custodial guardian is.
Emergency contact — someone other than the parents or guardians we can call.
Restricted access — anyone who may not have access to the child’s information or medical records.
Siblings — names and dates of birth, and whether they are already Be Well patients.
Authorization for Treatment, Receipt of Rights, and the HIPAA release form — signed by the guardian.

Before you come in

Bring the child’s insurance card, immunization record, and any school or camp forms you need signed. Legal documentation is required for any custody arrangement, court order, or order of protection noted on the form — please bring the paperwork with you so we can record it correctly.

Download the Pediatric New Patient Packet (fillable PDF)

Questions before the visit: (718) 253-9355.