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Incoming New Patient Questionnaire

Please complete all sections carefully. Fields marked * are required.

Instructions: Complete the form below and click Submit Form. You may also Print / Save as PDF for your records before submitting.

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1. Patient(s) Information
# Patient Name * Date of Birth * Medical Problems / Daily Medications
1.1
1.2
1.3
1.4
1.5
2. Current Health Insurance

Select all that apply:

3. Previous Physician / Practice
4. Reason for Transferring
5. How Did You Learn About Us?
6. Practice Policy Agreements

Are you willing to abide by the policies of Columbus Children's Clinic, LLC on:

6.1 Visits by appointments only

6.2 24–72 hours lead time for requests on shot records, school forms, WIC forms, FMLA and other patient care related letters and applications

6.3 Outside treatment referrals when necessary for patient care

6.4 Administering vaccines for all vaccine preventable diseases

6.5 Parent/guardian responsibility for informing us of address changes, insurance changes, telephone number changes, and denied claims

7. DFACS Involvement

Was DFACS (Division of Family and Children Services) ever involved with any of your children?

8. Cell Phone & Recording Policy

Parent/guardian agrees that no cell phone use is permitted while the provider or staff is present in the room, and that audio or video recording by the parent/guardian or any family member is not allowed.

9. AI Scribe Disclosure

This clinic uses an AI scribe to assist with clinical documentation. Parents or guardians are informed at the beginning of the visit, and verbal consent is obtained. Please notify the provider at the start of the visit if you do not consent to its use.

Certification & Signature

By typing your name below and submitting this form, you certify that all information provided is true and accurate to the best of your knowledge. This constitutes your electronic signature.