New Patient Forms

In order for your child(ren) to be seen, you will need to fill out the “New Patient Paperwork” packet for each child. In addition, if your child is coming from a different pediatrician or healthcare provider, a “Medical Record Release Form” will also need to be filled out for each child. You may download the following PDF forms or pick them up at our office. The PDF files marked “Fill & Sign” are made so you can type right on them. You will be able to email them to us shortly (Spring 2020).

(Adobe Acrobat required.) – click here to go to Adobe to download Acrobat. (You will leave our site.)

New Patient Paperwork (Fill & Sign)

Medical Record Release Form (Fill & Sign)

Notice of Privacy Practices

Consent to Treat

Consent to Treat – Telemedicine

For patients with Commercial Insurance, please read our Credit Card on File Policy prior to your first appointment:

Gateway Pediatrics Credit Card on File Policy

Statement Fee

Established Patient Forms – Yearly Update

Like most offices, we need to make sure we have the most accurate information. Please complete these forms prior to your child’s first appointment of 2020. We hope this form is easier by allowing multiple names on one form. 

Yearly Update Form – 2020 (Fill & Sign)

Please mail or drop off forms to:
Gateway Pediatrics, PA
1415 Wesley Drive
Salisbury, MD 21801

You may also fax them to our secure fax server at 410-912-4202.

If you have any questions, please call our office at 410-912-7000.

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