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Patient Enrollment · Recommended

Enroll New Pediatric Patients and Capture Vaccine History

Streamline pediatric new patient enrollment with one form for child and guardian details, health history, vaccine status, and immunization record uploads.

Use This Template Free Preview

Aura theme

formbuilder.ai/f/pediatric-clinic-new-patient-enrollment-immunization-history-form

Pediatric Clinic New Patient Enrollment & Immunization History Form

Child's Full Legal Name

· · ·

Child's Date of Birth

· · ·

Child's Sex Assigned at Birth

Submit

This pediatric new patient enrollment and immunization history form gives your practice a friendly, organized way to welcome new families. It opens with a warm greeting and collects the essentials: the child's full legal name, date of birth, and sex assigned at birth, along with the parent or legal guardian's name, relationship to the child, mobile phone, email address, and home address. Parents then complete a focused health history section covering known allergies (including latex and vaccine ingredients), current medications, vitamins and supplements with dosages, and a checklist of existing medical conditions.

The template is built for pediatricians, family medicine practices, pediatric urgent care centers, community health clinics, and school-based health programs that need a complete picture before a child's first appointment. A dedicated immunization section lets parents mark the status of each vaccine, report any past serious or allergic vaccine reactions, and upload a vaccine card, state registry printout, or prior clinic record. Asking for the previous pediatrician or clinic name also makes requesting a records transfer quick and simple.

Replacing clipboards and paper packets with an online form shortens waiting room time, reduces transcription errors, and helps your clinical team spot allergy risks and vaccine gaps before the visit begins. A closing insurance and consent section rounds out the enrollment so your front desk receives everything in a single submission. Customize the fields, add your clinic's branding, and share the link on your website or in appointment confirmations so families can finish enrollment from any phone or computer.

4 Pages

19 Questions

~6min To complete

Free No credit card needed

Field types Full Name ×2 Dropdown ×2 Long Text ×2 File Upload ×2 Date Single Choice Phone Email Address Multiple Choice choicematrix Yes / No Short Text termsandconditions Signature

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 Child & Parent/Guardian Information 8 questions

Child & Parent/Guardian Information

Welcome to our practice! We're so glad you've chosen us to care for your child. Let's start with some basic information about your child and the parent or legal guardian completing this form. Your information is kept confidential and is used only to give your child the best possible care.

1 Child's Full Legal Name * Full Name

2 Child's Date of Birth * Date

3 Child's Sex Assigned at Birth * Single Choice

4 Parent/Legal Guardian Full Name * Full Name

5 Relationship to Child * Dropdown

6 Parent/Guardian Mobile Phone * Phone

7 Parent/Guardian Email Address * Email

8 Home Address * Address

Page 2 Health History 3 questions

Health History

1 Known Allergies (food, medication, latex, or vaccine ingredients; write None if none) * Long Text

2 Current Medications, Vitamins & Supplements (include dosage) Long Text

3 Existing Medical Conditions (select all that apply) * Multiple Choice

Page 3 Immunization History 4 questions

Immunization History

1 Vaccine History (select a status for each vaccine) * choicematrix

2 Has your child ever had a serious or allergic reaction to a vaccine? * Yes / No

3 Immunization Records (vaccine card, state registry printout, or prior clinic record) File Upload

4 Previous Pediatrician or Clinic Name (for records transfer) Short Text

Page 4 Insurance & Consent 4 questions

Insurance & Consent

You're almost finished! Please share your child's insurance information and review the consent below. If you have any questions about coverage or our policies, our front desk team is always happy to help.

1 Primary Insurance Type * Dropdown

2 Insurance Card (Front & Back) File Upload

3 I confirm I am this child's parent or legal guardian. I consent to medical evaluation and treatment, authorize the clinic to request records from previous providers and to access and update my child's state immunization registry record, and acknowledge the HIPAA Notice of Privacy Practices and financial policy. * termsandconditions

4 Parent/Legal Guardian Signature * Signature

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.