If you are an existing patient of Dr. Kimberly Dudley or Ms. Sara Dillon and are unable to come to the clinic before October 11, 2024, please download this form and provide the remaining information requested. This form is for current patients only.
We request that you send a scanned copy of the form to admin@setapartpediatrics.com. This is a HIPPAA-compliant, protected email address.
Please include your child's name, date of birth, and social security number.
The middle portion of the form has already been filled out so all that is needed is a signature and date at the bottom as well as relationship which in most cases will be mother or father. Please also have someone else (spouse, coworker, etc) sign the witness line if this is being submitted online.
Again, this is the only information needed and you may leave the remainder of the form blank.