Please fill out the form below to transfer to our office. After submission, a member of our staff will review the application and communicate further.

PLEASE DO NOT FILL OUT A RECORDS RELEASE UNTIL INSTRUCTED TO DO SO

Four Seasons Pediatrics Transfer Registration

Dear Parent,

When parents request to transfer from another pediatrician, we request some information. This helps us understand what the need is and whether we can serve those needs in the best interest of the child and the family

What is the primary reason you wish to establish with our practice?

What did you like about your previous pediatric office?

What did you not like about your previous pediatric office/What made you leave?

We only see patients for urgent care visits if we are the primary care provider.

I understand

We follow a schedule to vaccinate children according to the vaccine schedule found on our website. Would you commit to this schedule? (note: we do not require the HPV, Influenza, or COVID vaccines)

Yes

Parent Name

Phone

Sincerely,

Four Seasons Pediatrics

Please fill out the form below to transfer to our office. After submission, a member of our staff will review the application and communicate further. PLEASE DO NOT FILL OUT A RECORDS RELEASE UNTIL INSTRUCTED TO DO SO

Four Seasons Pediatrics Transfer Registration

Please fill out the form below to transfer to our office. After submission, a member of our staff will review the application and communicate further.

PLEASE DO NOT FILL OUT A RECORDS RELEASE UNTIL INSTRUCTED TO DO SO