Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the Pediatric Intake Form and open it for editing.
2. Enter today's date at the top of the form to indicate when it is being filled out.
3. Provide your child's name, parent/guardian names, age, date of birth, and gender in the specified fields. Ensure accuracy in this critical personal information.
4. Fill in the child's Social Security number in the designated area to provide necessary identification details.
5. Complete the address section with your current residential information, including city, state, and zip code.
6. Include a cell phone number and email address for communication regarding your child’s care.
7. Specify your insurance company and the name and date of birth of the insured individual in your family.
8. Input your primary care physician's information and their office phone number for reference.
9. Identify an emergency contact person and their phone number to ensure swift communication if necessary.
10. Indicate how you learned about East Valley Naturopathic to help the organization improve outreach.
11. Choose whether to be added to their newsletter email list by marking 'Yes' or 'No'.
12. List your child’s primary health concerns in order of importance, providing a brief description for each.
13. Check all relevant boxes under the medical history section to document known allergies, surgeries, and health events.
14. Mark whether specific childhood illnesses are current or past, using 'C' for current and 'P' for past.
15. Complete the family history section, indicating any relatives with pertinent health conditions.
16. List all medications your child is currently taking or has taken in the past, including supplements.
17. Describe any dietary restrictions, sensitivities, or intolerances your child may have.
18. Document your child's immunization history by indicating received vaccines and noting any reactions.
19. Provide details on prenatal and neonatal history, including any complications or health issues during those periods.
20. Fill in social history, including whether your child attends daycare or school, and provide insight into their social and academic performance.
21. Complete the informed consent section by reading through the provided terms, signing, and dating the form.
22. Review the financial policy for East Valley Naturopathic before signing the acknowledgment.
23. Upon completing all sections, save your changes, and then choose to download, print, or share the form as needed.

Take the time to complete your documents online today for a smoother experience in your child’s care.