ONLY submit this form once you have spoken with a staff member of Rutherford Pediatrics regarding becoming a new patient. If you have not done so, please call (201) 842-0501 during our regular business hours for further instructions.
If you have spoken with our staff, please fill out one form for each child you are registering as a patient.
CLICK THE ICON TO OPEN OUR EMAIL TEMPLATE!
Upon completing this form, please send CLEAR IMAGES of the following documents to firstname.lastname@example.org
in the format: (Insert Child's Name) - Records/Insurance Card
Front and Back of Insurance Card
Last Well Visit/Physical Exam Records