Become a Patient

To become a new patient, first contact your insurance company to change the PCP to Pediatrics West, then complete the Registration Form, including signature documents, and return all to our office prior to your first appointment. Please note that we are currently accepting patients through age 18.

We also request you submit the Authorization to Use and Disclose PHI form to your previous physician to transfer all records to our office. Please have all previous records mailed to:

Pediatrics West, PC
ATTN: Medical Records
133 Littleton Road
Westford, MA 01886

Records can also be faxed to:
978-692-904

Please call our office at (978) 577-0437 to schedule an appointment for your child.

Patient Registration Forms (Online Versions)

Please select the Patient Registration form below based on the patient’s age. Registration Forms submitted on-line will be processed within 24 business hours Monday-Friday.

New Patient Registration Form for under the age of 18 (online version)

New Patient Registration Form, ages 18 and over (online version)

Registration Form (Print Version)

To become a new patient, please complete the Registration Form, including signature documents, and return all to our office prior to your first appointment.

We also request you submit the Authorization to Use and Disclose PHI form to your previous physician to transfer your records to our office and contact your insurance company to change the PCP to Pediatrics West prior to your first visit.

Registration Form (print version)

Other Forms

To become a new patient we request that you submit the “Authorization to Use and Disclose PHI” form to your previous physician to have your records transferred to our office prior to your first visit.

Authorization to Use and Disclose PHI

Consent to See and Treat

Divorced Parents – Informed Consent

HIPAA ~ Acknowledgement Form Minors

HIPAA ~ Acknowledgement Form 18+