Pre-Registration Form

Shores Pediatrics

*To be filled out within 3 days of your appointment only

Patient Name*

First Name:*
Last Name:*
Email:*
Patient Date of Birth*

Parent's Name*

First Name:*
Last Name:*

Address*

Street Address:*
Address Line 2:*
City:*
State / Province / Region:*
Postal / Zip Code:*
Country:*

Cell Phone (of parent that will be bringing patient)*
Appointment Date*

Insurance Information

Insurance Provider: *
Policy Number: *
PO Box (located in the back of your card): *

FOR OFFICE USE ONLY

_ Insurance Verified
_ Copay and Balance
_ Encounter
_ Additional:

BOOK AN APPOINTMENT TODAY!

Request an appointment

Our commitment to caring for your family is now available around the clock. Our physical office location may currently be closed, but you can still call (954) 752-9220 to speak with a trusted medical team member at our after-hours call center.

If you are experiencing a medical emergency, please call 911.

Please note: At this time, our office does not provide medical exemptions for masking where mandated.

Our providers and staff support mask mandates, especially in school settings, to effectively and safely prevent the spread of COVID-19.

Your child's health is our priority!