Reading Pediatrics Associates


First & Last Name:
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Relationship to Patient:	Mother Father Guardian Other
Patient Name:
Patient Age:
First time visitor?	Yes No if yes, please fill out the following:
	Street Address:
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Preferred times: (check all that apply)	M-F: 8:30am-12:00pm M-F: 1:30-6:00pm Sat.: 9:15am-12:00pm
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