register in advance with your Cook Children's pediatrician

Patient Registration Form: English | Spanish
Select the desired version from the above links to open the registration form using Acrobat Reader. Once opened, print the form and follow the instructions below.

What is the purpose of this form?
Completion of registration paperwork will provide current address and insurance information for your child's medical record. Completing this registration form prior to your child's scheduled appointment will decrease your wait time and expedite your visit at your pediatrician's office.

Who should fill it out?
New patients and existing patients with new address and/or insurance information.

What they should do once completed?
Please bring your completed registration form to your child's next scheduled appointment.

Who to contact if they have questions?
Please call your pediatrician's office for assistance.