Patient Forms

How to become a patient at KidMed:

Step 1: Call our friendly staff at 409-363-5711 to request to become a new patient or complete our New Patient Registration form.

Step 2: If approved, contact your previous pediatric clinic to request that your medical records be sent to KidMed. The fastest way is for the previous clinic to directly fax them to us at: 409-363-5712. You will need to sign a release of information (ROI) form to release the records. If you cannot get one from your previous clinic, we have one for you here.

Step 3: Fill out the New Patient Forms below. Every patient at KidMed needs to fill these out even if they are a previous patient of Dr. Bell. You can turn these forms in before or at your child’s first appointment.  Expectant mothers only need to complete the KidMed Pre-registration Form.

Step 4:Call for an appointment. Call us during business hours at 409-363-5711 to schedule an appointment.

Please note: appointments cannot be made outside of business hours.

*KidMed is currently only accepting newborns of first time moms with commercial (private) health insurance.

Child writing

Patient Forms

  1. KidMed Medical History
  2. KidMed Consent & Authorization Form
  3. KidMed Patient Information
  4. KidMed Policy Signature Pages
  5. KidMed Practice Policies
  6. KidMed Release of Information (ROI)
  7. New Patient Registration Form

Expectant Mothers Only:

Please contact our office at 409-363-5711 or stop by during clinic hours to get our pre-registration form.

This form must be filled out and approved before your little one arrives.