Thank you for your interest in Pediatrics Plus. Please fill out the below enrollment form and bring it with you to the clinic, so we may know how our services can best assist your family. Get started today by filling out the below welcome packet that corresponds with your state.

  

First Name*

Please let us know your first name.

Last Name*

Please let us know your last name.

Phone*

Please let us know your phone number.

Email*

Please let us know your email address.

Home Address*

Please let us know your address.

City, State*

Please let us know the city and state in which you live.

Child's Name

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Child's Date of Birth*

Please let us know the date of birth for your child.

Insurance Carrier – Medicaid or Private Insurance

Member ID

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Policy Holder

Policy Holder DOB

Group Number

Medicaid Number

Enrollment Month*

Select An Enrollment Month*JuneJulyAugustAny Please select an enrollment month.

Locations*

Select A Location*Alma, ARArkadelphia, ARConway, ARFrisco, TXLittle Rock, ARNorth Little Rock, ARRussellville, ARSherwood, ARVan Buren, ARCounseling & Diagnostics, Little Rock, ARAny Please select a location.

Select Reason(s)*

Tour A Facility

Physical Therapy

Occupational Therapy

Speech Language Therapy

ABA Therapy

Developmental Preschool

Counseling & Testing Services

Other

Please select a reason.

Where Did You Hear About Us?

Select OneSocial Media Online TV Magazine Newspaper Radio Local Event Friend Doctor MailerTherapist Blog/InfluencerBillboard RisePrevious PatientEI Service Coordinator Invalid Input

Add Summer Camp?

YesNo Invalid Input

Comments

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