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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.


Upon completing this form, please send CLEAR IMAGES of the following documents to 
in the format: (Insert Child's Name) - Records/Insurance Card

  • Immunization Records

  • Front and Back of Insurance Card

  • Last Well Visit/Physical Exam Records


You will only be considered a patient at Rutherford Pediatrics once we receive your completed patient registration form and clear images/PDFs of the required documents (listed above). After you submit the necessary information and we review it, one of our staff members will call you at the number you provide to inform you of your updated status as a registered patient. From that date onwards, you will be allowed to schedule your first appointment. 

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