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New Patient Registration

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.

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.

*Note: completion of this survey is not a guarantee of acceptance into the practice.

2. Are you willing to adhere to the Academy of Pediatrics and CDC recommended vaccine schedule?
4. We sometimes provide needed services that are either not fully covered or not covered by some insurers. Examples include hearing and vision screening, doctor visits that insurers believe are for “mental health” reasons, and some in-office labs. In such cases, are you willing to pay for these services yourself?
5. Village charges a modest per child fee (our Added Benefits Fee) to cover a variety of administrative services not covered by insurance. This fee also allows our practice to remain small and personalized. Are you comfortable paying this mandatory fee yearly?
6. Are you recently moving to the area from out of state?
10. Are you a medical doctor?
14. Preferred Physician

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