Enrollment Form
Request form for enrollment into Head 2 Toe Pediatrics, PLLC
* Required
Email address
*
Your email
Phone number
*
Your answer
Address
*
Your answer
Full Name
*
Your answer
Relationship to child
*
Parent
Grandparent
Family member
Other:
Current pediatrician and/or OB physician (if pregnant)
*
Please provide full name and address
Your answer
How many children would you like to enroll?
*
1
2
3
4+
Please list full names and date of birth of all children that you will be enrolling
*
Your answer
How many children will you enroll in our membership plan?
Family maximum for 2 children $300/mon. Family maximum for 3+ children $350/mon. Discounts for plans paid yearly.
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2
3
4+
Membership: Little Nuggets (0-2 yrs), $250 monthly
Membership: Little Monsters (3-6 yrs), $150 monthly
Membership: Little Tweenagers (7+ yrs), $90 monthly
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2
3
4+
Membership: Little Nuggets (0-2 yrs), $250 monthly
Membership: Little Monsters (3-6 yrs), $150 monthly
Membership: Little Tweenagers (7+ yrs), $90 monthly
How many children will you enroll in our A La Carte packages?
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2
3
4+
Newborn Package, $1,500 one-time
Urgent Care Package, $900 one-time
Celebrity Package, $2,000 one-time
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2
3
4+
Newborn Package, $1,500 one-time
Urgent Care Package, $900 one-time
Celebrity Package, $2,000 one-time
How many children will you enroll in our pediatrician partnership program?
This program allows families access to Head 2 Toe Pediatrics, PLLC for sick and urgent care needs, while still maintaining a relationship with their pediatrician. This program will require proof of active participation with a local St.Pete / Tampa pediatrician. The yearly access fee is $300 and any at-home visits are charged when requested, at an hourly rate of $200.
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4+
Pediatrician Partnership
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Pediatrician Partnership
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