Request to Join Pediatrics On Call
Please complete this request to join and we will contact you within 24 hours with patient intake forms via the email listed below to set up your membership and get your medical kit on its way to you!  

**Membership is $15.99/mo for one child or $19.99/mo for more than one child (from the same family) and a one-time registration fee per family of $100 (+ tax and shipping) which includes your medical kit with a digital otoscope for examining the ears, a digital thermometer, and a pulse oximeter.

Email us at pediatricsoncall247@gmail.com with any questions!
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Email *
Patient #1 Name (First, Middle, Last): *
Patient #1 Date of Birth (mm/dd/yyyy) (0-18 years of age only please): *
Patient #1 Gender *
Primary Pediatrician (MUST have a PCP): Name, address, phone: *
Parent/Guardian Names and Relation to Child (List only those authorized to make health care decisions for the child): *
Residential Address (MUST reside in Florida): *
Mailing Address (Where you want your medical kit shipped): *
Best Cell Phone Number for Telehealth Phone and Video Visits and Contact Number: (xxx) xxx-xxxx *
Additional children's names (first, last), dates of birth (0-18 years of age only), and gender (M/F/Prefer not to say) from your family that you would like to add to the membership.  If no other children, please respond "None": *
If you prefer an iPhone Compatible Otoscope for an additional $10 + tax, please click "Yes" below.  If not, click "No". *

By typing my full name and completing the credit card information below, I authorize Pediatrics On Call to save the credit card(s) indicated below on file.

I authorize Pediatrics On Call to process the credit card below as "Card on File" and charge in accordance with the agreed upon payment plan between the practice and me (including the one time charge for the registration fee with medical kit and the monthly membership fee).

I understand this authorization will remain in effect until the expiration of the credit card account. I may also revoke this form by submitting a written request to the medical practice.

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16 digit credit card number (This information will be deleted upon activation of your account and is never stored in Google Forms):
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Name on credit card (This information will be deleted upon activation of your account and is never stored in Google Forms):
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Expiration date MM/YY (This information will be deleted upon activation of your account and is never stored in Google Forms):
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3 digit security code from the back of the card (This information will be deleted upon activation of your account and is never stored in Google Forms):
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Billing zip code (This information will be deleted upon activation of your account and is never stored in Google Forms):
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I am the parent/guardian of this patient: *
How did you hear about us? *
Other
A copy of your responses will be emailed to the address you provided.
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