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Vital AZ Concierge Pediatrics-New Patient Questionnaire
Please complete the information below to hold a spot for your newborn with our practice!
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* Indicates required question
Email
*
Your email
Please provide parents names, address and phone number
Your answer
What is your due date?
MM
/
DD
/
YYYY
Where will you be delivering?
Hospital
Home birth
Other:
Clear selection
Who is your OBGYN or Midwife?
Your answer
What are you looking for most in a pediatrician?
Your answer
Are you planning to administer vitamin K to your newborn?
Yes, oral
Yes, shot
No
Undecided
Clear selection
Are you planning to vaccinate your child?
Yes, standard schedule
Yes, modified schedule
No
Undecided
Clear selection
If your child is a boy, do you plan on circumcision?
Yes
No
Undecided
Clear selection
Any Allergies or Special Medical Conditions That Run In Your Immediate Family?
Your answer
Are there any past medical experiences for you or your children that have disappointed you in regards to your medical care?
Your answer
A copy of your responses will be emailed to the address you provided.
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