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.

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

New Patient Paperwork

Medical Record Release Form

Notice of Privacy Practices

Consent to Treat

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

Please mail or drop off these forms at:

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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