• New Patient Form

    Please fill out the information below.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Introduction:
    Thank you for your interest in establishing a patient-doctor relationship with our clinic. A New Patient Coordinator will review the information you provide and contact you within the next 14 days.


    As a brief introduction to our clinic, you may want to visit our website at adapediatrics.com. We are open Monday – Friday from 8:30 to 4:30 and a nurse or physician is available after hours for urgent issues. We offer timely care for all our patients and ask that you respect our time by limiting “no-shows” which take away from another patient’s ability to be seen at that time slot. We have a policy of allowing only three “no-shows.”


    Our mission is to ensure the health and well-being of all our patients by, among other things, working to avoid vaccine-preventable diseases. Therefore, we do not offer delayed vaccine schedule plans.

    • We ask that all our patients follow the vaccine schedule recommended by the American Academy of Pediatrics and the Centers for Disease Control. However, at this time, the COVID-19 vaccine is available in our office for most age groups but this is not a requirement to be a patient in our office.
    • Prior to being accepted as a patient at Ada Pediatrics, the New Patient Coordinator will verify that the child is current on vaccines. (Please upload a copy of your child’s immunization record.)
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Questionnaire:

  • Why are you looking for a new pediatrician?
  • Does your child have Medicaid?

  • Dr. Lindsay accepts most Medicaid patients who accept our vaccine policy and who establish with Ada Pediatrics, P.A. as the child’s Primary Care Provider (PCP) through Healthy Connections. Once the New Patient Coordinator have approved your request to move to our office, you must contact Health Connections at 888-528-5861 to check whether you are eligible to change PCPs and to let them know you want to have Ada Pediatrics listed as your PCP. We will not schedule an appointment until this is completed.

  • Does your child have private insurance?

  • It is recommended that you check with your insurance carrier to ensure Ada Pediatrics, P.A., Ryan Lindsay, D.O. and R.E. Lindsay, M.D. are in network.

  • Do you agree to vaccinate your children as recommended by the American Academy of Pediatricsand the Centers for Disease Control?

  • Parent Information

  • Guardian #1
  • Format: (000) 000-0000.
  • DOB
     - -
    2 digit month, 2 digit day, 4 digit year
  • Guardian #2 (If Applicable, or hit next)
  • Format: (000) 000-0000.
  • DOB
     - -
    2 digit month, 2 digit day, 4 digit year
  • Preferred Appointment Reminder
  • Format: (000) 000-0000.

  • Please list children oldest to youngest.

  • Gender
  • DOB
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender
  • DOB
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender
  • DOB
     - -
    2 digit month, 2 digit day, 4 digit year

  • Primary Insurance Information (For each Insurance listed above, please upload a copy of your insurance card – front and back)

  • Policy Holder DOB
     - -
    2 digit month, 2 digit day, 4 digit year
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Seconday Insurance Information (For each Insurance listed above, please upload a copy of your insurance card – front and back)

    If applicable. If not hit hext.
  • Policy Holder DOB
     - -
    2 digit month, 2 digit day, 4 digit year
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Emergency Contact

    (List additional persons who may bring children for appointments or who we are authorized to communicate with.)
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • PATIENT PORTAL SIGN-UP:

  • Access to Patient Portal allows:

    • Two-way secure messaging
    • Appointment requests
    • Medication refill requests 
    • Access to the electronic health record
  • Type a question

  • ASSIGNMENT OF INSURANCE BENEFITS/ CONSENT TO TREAT/ PRIVACY POLICY

  • Please check boxes for acknowledgement and consent.
  • Should be Empty: