Pediatric New Patient Application

If you'd like to join our practice, please fill out this form. Once this is completed and approved, we will then send you a link to our patient portal to enter your demographic and insurance information. You can ask questions, request prescription refills, download your results, and even schedule your own appointments. This service is offered for free for all existing and new patients.

We are currently only accepting 1 new patient per provider per day, due to a high census. We are only accepting new patients from the insurances in the drop down below. If your insurance is not on the drop down, we are not taking new patients from your insurance company.

We are accepting new cash patients, and are finishing up a subscription primary care model. For $60/month, you can receive all the primary care services you need, including free telehealth, free labwork (from a menu), and soon free medications. Please let us know if you’d be interested.

Child's Name *
Child's Name
Parent or Guardian's Name *
Parent or Guardian's Name
Are you applying to be seen for medical care, behavioral counseling, or both?
Payment and No-Show Policy *
Atembis LLC requires payment of copay at time of visit, outstanding balances are due immediately, and no show fee for failure to show or cancel within 24 hours of a visit ($80 for medical, $120 for behavioral visits). By checking below, I understand and agree to this policy.
Address *
Address
Date of Birth *
Date of Birth
Date of Birth
Parent's Cell Phone (or home # if no cell phone) *
Parent's Cell Phone (or home # if no cell phone)
Other Phone
Other Phone
Please choose your insurance (or cash) plan. We do NOT accept any AHCCCS plans. If you are unsure if we accept your insurance, please contact your insurance carrier first. If your insurance is not on this list, it is likely that we do not accept it. We do not accept third party billing or payment agreements.
Please enter your insurance ID number here. This will help determine that you are on an insurance plan that we accept. If you are self-pay, please leave this blank.
Please enter your group number. This also helps to determine if we are within your insurance network. If you don't have a group number or are self-pay, please leave this blank.
Click on all medical problems your child has or has had: *
Any cancer history? *
Has your child ever had surgery? *
This is generally to ask if you've ever had a procedure which required general anesthesia
Medication Agreement *
We here at Atembis LLC are actively involved in reducing the epidemic of prescription drug abuse in our community. It is for this reason that it is important that all new patients understand that 1) we do NOT write any regular prescriptions of opiates for new patients, 2) that we discourage the dependence on all schedule drugs (including medications such as Ambien, Xanax, etc) and will require seeking ways to help patients with their issues without the use of narcotic medications, and 3) we will screen all patients using the Arizona Controlled Substances Prescription Monitoring Program. By clicking below, you agree and understand our office policies regarding narcotic medications, and provide us consent to review the CSPMP database along with your Pharmacy Benefits Manager database.
Please list all of your current medications, including any over the counters you may be taking, along with dosage and frequency. If you are not currently taking any medications, please write NONE
Please list any allergies to medications you may have. If you have none, please write NONE
Family History (Father) *
Any family history for your father?
Family History (Mother) *
Any family history for your mother?
Family History (Sisters) *
Any family history for any sisters?
Family History (Brothers) *
Any family history for any brothers?
Birth History - Check all that apply *
School difficulties *
In the past year, has your child encountered difficulties in school such as bullying, suspension, detention, or expulsion?
Immunizations *
Is your child up to date on all of his/her immunizations? We do not sign waivers, and are strong advocates of immunizations in all children. We will do all we can to make sure your child is adequately immunized against all available illnesses.