Request an Appointment
Welcome to Lighthouse Pediatrics! We are pleased that you have chosen to establish your child in this special practice. In order for us to use your time with the doctor wisely, could you please take a few moments to complete the following information about your child?
Name of Child:
Date of Birth:
Does your child have any ongoing medical problems?:
If yes, please list
Specialist(s), if any:
Does your child have any past medical problems which he/she's outgrown?:
Has your child spent the night in the hospital?
Please list with approximate date(s):
Is your child on medications (include prescription and over-the-counter)?
If yes, please list along with doses:
Does your child have any allergies?
Please choose any of the conditions that run in your family (parents, aunts/uncles, grandparents and siblings) and what family member is affected.
Crohn's oor Ulcerative Colitis
High blood pressure
Prolonged QT syndrome
Sudden Unexplained death
Who lives in the house with your child?
Do you own any pets?
If yes, type of pet:
Are there any smokers in the home?
Do you have any water near your home?
If yes, please choose
Private PoolCommunity PoolLakeCanalOcean
If you have a private pool, do you have a pool fence?
If your child is 4 years or older, does he/she know how to swim?
Does you child attend a daycare or school?
Name of the daycare or school:
Does your child have any special needs in school or daycare?
If so, please list:
Do you have any questions/concerns you want to address today?
Do you have any prayer requests?
If you are an established patient, please use the portal. Click below to go to the portal website: If you are not already registered for the portal, you may call the office to sign-up.
Lighthouse Pediatrics Portal
You may use the form below to request NON-urgent appointments. Please do not include personal health information.