Request Appointment

(602) 866-0550

Pay Bill

Medical
Staff ›

Immunization
Record Request ›

Medication
Refill Request ›

Patient Resources ›

Medical Record Requests

Patient/Parent/Guardian Request ›
Third-Party Request ›

Forms ›

No Show and Late Policies ›

Employment Application ›

Patient Portal ›

Upload Documents ›

After-Hours Triage ›

AVAILABLE FOR EXISTING PEDIATRIX PATIENTS ONLY

Medical
Staff ›

Immunization
Record Request ›

Medication
Refill Request ›

Request
Appointment ›

Pay Bill ›

Forms ›

Parent Resources ›

Employment Application ›

Medical Record Requests
Patient/Parent/Guardian Request ›
Third-Party Request ›

No Show and Late Policies ›

Patient Portal ›

Upload Documents ›

After-Hours Triage ›

AVAILABLE FOR EXISTING PEDIATRIX PATIENTS ONLY

Patient Forms

Download and fax completed forms to (602) 993-5788.

English Forms
Spanish Forms

New Patient?

Please complete the following:

  • Demographic Sheet

  • New Patient/Newborn Sheet

  • HIPAA Sheet

Insurance or Demographic Changes?

Please complete the following:

  • Demographic Sheet

English Forms

Patient Demographics ›

New Patient Information Form – Newborn ›

New Patient Information Form – 1 Year Old+ ›

Permission To Treat ›

Record Release Form ›

HIPAA ›

Vaccine Questionnaire ›

Vanderbilt Form ›

Spanish Forms

Patient Demographics ›

New Patient Information – Newborn ›

New Patient Information Form – 1 Year Old+ ›

Permission to Treat ›

Record Release Form ›

Vaccine Questionnaire ›

Vanderbilt Original ›

Vanderbilt Follow Up ›

Please note: All forms are in PDF format and require software such as Acrobat Reader to be viewed.

Request Appointment

If your child requires a SICK or a SAME DAY APPOINTMENT OF ANY KIND do not use our form. Call the office for SICK or SAME DAY appointments: (602) 866-0550.

Request Appointment

Pediatrix at Black Canyon

  • 15650 N. Black Canyon Hwy, Ste.100
    Phoenix, AZ 85053
  • Phone: (602) 866-0550
  • Fax: (602) 993-5788
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Pediatrix at Happy Valley

  • 2030 W. Whispering Wind Dr.
    Phoenix, AZ 85085
  • Phone: (623) 869-9080
  • Fax: (623) 869-9090
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