503-123-1234
Office: 503-554-0036 | After-hours: 503-294-1732

New Patients

We welcome new patients to Dr. Ken Whittaker’s pediatric clinic!

We welcome all new patients to our office and we’re excited to help you make our practice your new medical home. Please take a moment to look through our Office Policies and Visit & Vaccine Schedule to familiarize yourself with our practices. We are available to answer any medical or administrative questions you may have to ensure a smooth transition into our clinic.

We’re so glad you chose Dr. Ken Whittaker to partner with you and your family as we work together to provide all appropriate services to ensure your child’s successful growth and development.

The New Patient Packet includes:

Checklist

Clinic Policies Checklist and Acknowledgement Form:

This document summarizes the required patient forms.

Patient Registration 

This form requests your address, phone number, emergency contact and insurance information. One registration needs to be completed per household. All minor children that will be patients of Dr. Whittaker should be listed on this form.

Initial History Questionnaire

This provides the doctor with information about your child’s past medical history.

Authorization to Disclose Medical Records 

This allows us to request copies of your child’s previous medical treatment.

Acknowledgment and Consent (HIPAA)

Our office provides a Notice of our Privacy Practices. This form indicates that you have received notice.

Authorization to Treat in the Absence of Parent or Guardian

Complete, sign and return this document if you anticipate that your child may be accompanied to their appointments by someone other than a parent or legal guardian.

Office Policies

This document provides information about our clinic policies. Please acknowledge receipt of this document. Please keep for your records.

Financial Policies

This outlines the clinic expectations for payment and reimbursement based on the type of coverage (if any) your child has. Please acknowledge receipt of this document. Please keep for your records.

New Patient Checklist and Forms Download
Print Before Your First Visit
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