New Patient Request

We are excited that you have chosen Oberlin Road Pediatrics to care for your family. We are accepting new patients under the age of 18. If you have a newborn being discharged from the hospital, please reach out to our office directly to register your baby. We will be welcoming new patients to our practice in a well-controlled manner to make sure we can continue to see our current patients as well as our new patients in a timely manner.

Before completing the request to become a patient of Oberlin Road Pediatrics, please read our Vaccine Policy and Office Policies. You will be asked to confirm that you read and understand our policies.

• Read Vaccine Policy
• Read Office Policies

Please complete and submit the form below and we will add you to our waitlist. You will receive a confirmation email that your request has been received. Once you have been added to the waitlist, we will reach out to you to start the onboarding process for your family.

Your Information

Parent Name:
Primary Phone:
Email Address:
Number of Children Joining:	123456789
Please reach out to your insurance directly to make sure we participate with your individual plan.
Insurance Provider:
We recommend that you review our vaccine policy prior to joining our practice. We are a vaccinating practice and follow the American Academy of Pediatrics (AAP) standardized schedule for implementation of vaccines. North Carolina State Law dictates the minimum requirements for vaccine administration for our patients.
I have read and understand the vaccine policy.	NOYES
I have read and understand the office policies.	NOYES