New Patient Registration

Welcome to Lockport Pediatrics! Please complete this secure form to begin the registration process. Our team will verify your insurance and contact you within 24 hours to finalize your account.

Need Help?

If you are having trouble completing this form or are unsure about your insurance coverage, please give us a call.

Contact: (716) 433-6711

Note: You can also fill out paper forms at the office. Please arrive 15 minutes early if you choose to do so.

Child's Full Name

Date of Birth

Gender

Male Female

Home Address

Preferred Pharmacy

Parent 1 Name

Relationship to Patient

Phone Number

Parent 2 Name (Optional)

Emergency Contact

Primary Insurance Company

Subscriber ID / Policy Number

Group Number

Policy Holder's Name & DOB

Upload Insurance Card (Front)

Upload Insurance Card (Back)

Previous Doctor/Clinic Name

Any Known Allergies?

Current Medications?

I certify that the information provided is accurate. I authorize Lockport Pediatrics to verify my insurance benefits and contact me via phone or email regarding this registration. I understand that this form submission does not guarantee an immediate appointment.

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Location

New Patient Registration

Need Help?