Pediatric Intake Form

Pediatric Care Intake Form

Pediatric Care: Minor illnesses & Infections, Sick Notes, Injuries, General Wellness, School Physicals

Please complete the form below to schedule a pediatric consultation with Nicole Baldwin, ARNP, from Hamilton Health & Wellness. A member of our team will contact you soon by email or text from 407-550-5441.

Name

Patient Date of Birth

Height

Weight

Blood Pressure

Allergies:

Current Medications:

Is the patient a female of reproductive age?

Yes No

If yes, is the patient pregnant or breastfeeding?

Yes No

Last Menstrual Period-if applicable:

Please list any past medical problems:

Surgical History:

Please list the reason for the telehealth consult:

Preferred Pharmacy Name:

Pharmacy Phone Number

Pharmacy Address:

Pharmacy City

Pharmacy State

Pharmacy Zip Code

Parent/Legal Guardian Name:

Parent/Legal Guardian Date of Birth:

Parent/Legal Guardian Email:

Parent/Legal Guardian Phone Number:

Parent/Legal Guardian Address:

Parent City

Parent State

Parent Zip Code

Please scan and upload a copy of your identification

Where did you hear about us from

I consent to the Terms Of Use, Privacy Policy, Patient Consent.

I consent I DO NOT consent

I consent to receive text and email messages from Hamilton Health & Wellness.

I consent I do not consent

View the Terms of Service, Patient Consent, and Privacy Policy