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Transfer Patient Application

If you are interested in making Village Pediatrics your child/children's medical home, please complete this survey so that we can ensure we are a good match for your family. Please also see the “Are We a Good Fit” page to ensure that you are aware of our policies.

Please also visit our insurance page to confirm that we accept your medical plan.

A member of our staff will contact you after receipt of the survey to further discuss our practice if we have openings. Please be aware that submitting the application in no way guarantees a spot in the practice.
Have you read and do you agree with the “Are We a Good Fit” checklist?:

Are you willing to adhere to the Academy of Pediatrics and CDC recommended vaccine schedule?:

If insurance doesn't cover some procedures or care, are you willing to pay for these services yourself?:

Are you comfortable paying this mandatory fee yearly?:

Are you recently moving to the area from out of state?:

Are you a medical doctor?: