New patients

Register your family with LPC

Complete one secure form for up to four children. Fields marked * are required.

What you’ll need

Each child’s legal name and date of birth
Parent or guardian contact information
Insurance details or a card image

This form does not ask for diagnoses, medications, allergies, medical history, or clinical concerns.

One family, one formEnter the household address once. Each adult provides their own phone number; children are not asked for phone numbers.

Household information

Children in this registration share this address.

Street address *City *State *ZIP code *Preferred language *Other language

Parents and guardians

The primary contact is the person completing this form. Additional contacts are optional.

Primary contact

Full name *Relationship to child or children *Phone number *Email address *No confirmation email is sent.

Contact address is the same as the household address

Contact street addressCityStateZIP code

optional additional contacts

Additional contact 1

Full nameRelationshipPhone numberEmail address (optional)

Additional contact 2

Full nameRelationshipPhone numberEmail address (optional)

Children

Add up to four children. Use each child’s full legal name. You do not need to re-enter the address or phone.

1 of 4 children added

Child 1

Legal name * Date of birth * Sex *

Child 2

Legal name * Date of birth * Sex *

Relationships for this child (optional)

Only change these when a contact has a different relationship to this child. Names appear below so you can easily identify each adult.

Primary contactAdditional contact 1Additional contact 2

Child 3

Legal name * Date of birth * Sex *

Relationships for this child (optional)

Only change these when a contact has a different relationship to this child. Names appear below so you can easily identify each adult.

Primary contactAdditional contact 1Additional contact 2

Child 4

Legal name * Date of birth * Sex *

Relationships for this child (optional)

Only change these when a contact has a different relationship to this child. Names appear below so you can easily identify each adult.

Primary contactAdditional contact 1Additional contact 2

Step 1 of 4

Appointment

Scheduling is optional. Choose what applies to your family.

Appointment preference *

Request and choose an appointment

I already scheduled with the office

Continue registration without an appointment

Choose nowNewborn: any available day. Well visit: two days out or later. Two to four children share one one-hour block.

Already scheduledDate and time are optional; your existing appointment stays unchanged.

No appointmentComplete registration only, without requesting an appointment.

Choose whether you need a new appointment, already have one, or want to register without requesting one.

Choose an available day. We assign the earliest time on that day first, and you may change it.

Visit type *

Available dayAppointment time

Newborn visits may be scheduled on any available day. New-patient well visits begin at least two days from today. Appointment times are offered between 10:00–11:30 AM and 2:00–3:30 PM.

VisitChoose a visit type

Children1 child

DateChoose a day

TimeChoose a time

Only available times are shown. Office-blocked or full times do not appear. If no suitable time appears, call the office.

Previous pediatrician

Optional information that can help our team.

Current or previous pediatricianReason for transferring

Step 2 of 4

Insurance

Enter the details, upload the card, or provide both. One method is required.

Enter insurance details

Insurance companySubscriber nameMember IDGroup number

upload the card

Front of cardJPG, PNG, or PDF · 5 MB maximumBack of card (optional)JPG, PNG, or PDF · 5 MB maximum

Step 3 of 4

Submission checklist

Family details need reviewAppointment choice needs reviewInsurance needs reviewRequired agreements need review

Review your information

Check these details before submitting. Use the Edit buttons to make changes.

This review is created in your browser. It is not sent or saved while the form remains in preview mode.

Household addressNot entered

Primary contact and relationshipsNot entered

Additional contacts and relationshipsNone added

Preferred languageNot selected

Previous pediatricianNot provided

ChildrenNot entered

Legal guardian documentNot required

AppointmentNot selected

InsuranceNot provided

Policy and consent

Please review the clinic policy and required submission statement.

Lincoln Pediatrics Vaccination Policy

Vaccination Policy for New Patients

At Lincoln Pediatrics Clinic, we follow the immunization recommendations of the American Academy of Pediatrics (AAP). We accept new patients only when the parent or guardian intends to follow the recommended routine childhood vaccination schedule.

If your child is behind on vaccines, we are happy to help your child catch up using the recommended catch-up schedule. We do not use alternative, selective, customized, or intentionally delayed vaccine schedules.

We recommend influenza (flu) and COVID-19 vaccination when appropriate, but neither vaccine is required to establish or continue care with our practice.

If you have questions, concerns, or are unsure about vaccination, please discuss them with our office before scheduling a new-patient appointment. We are happy to explain the recommended schedule and answer general questions before an appointment is made. Scheduling a new-patient visit means that you are willing to follow the routine schedule or an appropriate catch-up schedule.

Vaccination is an important part of protecting children and the community from preventable disease. When a child is not fully immunized, vaccine-preventable illnesses may need to be considered when the child becomes sick. Depending on the child's age and symptoms, this can lead to additional testing or treatment while serious infections are ruled out. Unvaccinated children may also place infants and medically vulnerable patients at greater risk of exposure.

If you have decided not to vaccinate your child with the routinely recommended childhood vaccines, Lincoln Pediatrics Clinic will not be able to accept your child as a new patient. We respect that families have different beliefs and make their own healthcare decisions; however, our practice has chosen to maintain this vaccination standard for new patients. We do not maintain a list of providers who accept patients whose families choose not to vaccinate.

Thank you for reviewing and understanding our policy. Our goal is to provide safe, consistent, evidence-based pediatric care to every family we serve.

I have reviewed and agree to follow Lincoln Pediatrics Clinic’s Vaccination Policy as a condition of joining the practice as a new patient. * I consent to the secure electronic submission and storage of this registration as described in the Website Privacy and Secure Submission Notice. * I consent to receive informational and conversational SMS messages from Lincoln Pediatrics Clinic, PA about appointments and administrative matters. Reply STOP to opt out or HELP for assistance. Message and data rates may apply. Message frequency may vary. Consent is not a condition of care. See our Privacy Notice and Text Messaging Terms.

Ready to submit?The primary contact above will be recorded as the person completing this form.

Step 4 of 4

Register your family with LPC

Household information

Parents and guardians

Primary contact

Children

Appointment

Existing appointment details

Previous pediatrician

Insurance

Enter insurance details

Submission checklist

Review your information

Policy and consent

Vaccination Policy for New Patients