Forms

New Patient Packet

If you are new patients transferring your family's care to East Elm Pediatrics, or new parents who have chosen us to care for your new baby, please complete the forms below and bring them to your first appointment. Be sure to fill in these forms honestly, completely, and to the best of your ability.

New Patient Packet

    Please complete this demographic sheet for children under eighteen years old. If your child is eighteen or older, please replace the Minor Patient Demographic Sheet with the Adult Patient Demographic Sheet, listed below.
    Please complete this questionnaire with information about your child's medical history and your family's medical history.
    Please read through the East Elm Pediatrics Notice of Privacy Practices. Once you have done so, please complete the Acknowledgement of Notice of Privacy Practices, listed below. The Notice of Privacy Practices is available for your personal records and does not need to be returned to our office. However, please be sure to complete the Acknowledgement.
    Once you have read East Elm Pediatric's Privacy Practices, listed above, please complete this form, acknowledging you have done so.

Other Forms

    If you want to transfer your child's care to or from East Elm Pediatrics, please complete this form and return it to our office.
    Once your child turns eighteen, they must complete an Adult Demographic Sheet. This demographic sheet replaces the one you filled out for them as a minor. Please bring it to the office as soon as possible.
    If you would like to submit photographs of your family to be displayed on the Homepage of our website, please complete this consent form and return it to our office. Photographs for consideration can be emailed to Helen at helenibclc@verizon.net.

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News @ East Elm

  • Patient Portal Is Now Open!

    The Patient Portal allows you secure, convenient communication with our office, 24/7.
     
  • Pay Your Bill Online!

    Did you know you can now quickly and easily pay your bill online?
     
  • Visit Our Facebook Page!

    East Elm Pediatrics is now on Facebook! Please follow the link to like, follow, and share our page.
     
  • Monthly Staff Meetings

    East Elm Pediatrics holds monthly staff meetings on the first Wednesday of every month. On these Wednesdays, our office will remain open as usual until 8pm, but between 5-7pm we will only see walk in Urgent care patients. 
     
  • Homepage Patient Portraits

    The pictures on our Homepage feature our own patients!
     
  • Flu Vaccine

    Flu vaccine now available!
    Call and schedule your childs appointment.
     
  • Pediatric Urgent Care!

    Happy New Year! We now have extended office hours and Pediatric Urgent Care!