Our Clinic
About Us
Our Team
Why Choose Us
Your First Visit
How to Find Us
Advice and Resources
Learning Library
Links
Forms
Make a Payment
Contact Us
Call Us: 316-283-7100
New Patient Information
Please fill out the information below before we schedule an appointment. (Alternative: printable
new patient packet - needs physical signature
) For children to be seen at Cottonwood Pediatrics (Newton, KS)
Preferred Pediatrician
Dr. Jon Jantz, MD, FAAP - 6 months and younger
Dr. Alyssa Watkins, MD, FAAP, IBCLC
Dr. Tomica Blocker, MD, PhD, FAAP
Tarina Gfeller, APRN, CPNP-PC
Maureen Entz, APRN, CFNP, CPNP-PC
For Newborns: name of the facility where baby was born
Child Name
*
First
Middle
Last
Child Date of Birth
*
MM slash DD slash YYYY
Legal Gender
*
Female
Male
Race
Rather not say
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian or Other Pacific Islander
White
Other Race
Ethnic Group
Rather not say
Hispanic or Latino
Not Hispanic or Latino
Main Phone Number (text reminders and/or calls)
*
Social Security Number
Address
*
Street Address
Address Line 2
City
ZIP / Postal Code
Parent Information
Parent 1 Name
*
First
Middle
Last
Parent 1 Date of Birth
*
Parent 1 Legal Gender
*
Female
Male
Parent 1 Social Security Number *
Parent 1 Place of Employment
Parent 1 Contact Information
Parent 1 phone is different
Parent 1 address is different
Parent 1 Phone
Parent 1 Email
Parent 1 Address
Street Address
Address Line 2
City
ZIP / Postal Code
Parent 2 Name
First
Middle
Last
Parent 2 Date of Birth
Parent 2 Legal Gender
Female
Male
Parent 2 Social Security Number
Parent 2 Place of Employment
Parent 2 Email
Parent 2 Contact Information
Parent 2 phone is different
Parent 2 address is different
Parent 2 Phone
Parent 2 Address
Street Address
Address Line 2
City
ZIP / Postal Code
Insurance Information
Insurance Card - Front
Accepted file types: jpg, jpeg, gif, png, pdf, tiff, Max. file size: 8 MB.
Insurance Card - Back
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Our Clinic
About Us
Our Team
Why Choose Us
Your First Visit
How to Find Us
Advice and Resources
Learning Library
Links
Forms
Make a Payment
Contact Us
Call Us: 316-283-7100