Child's Information *

First Name

Last Name

Birthdate *

(###)

###

####

Biological Sex

Male

Female

Other

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name

First Name

Last Name

Phone

(###)

###

####

Preferred Contact Method

Phone

Email

Text

Name

First Name

Last Name

Phone

(###)

###

####

Please check all that apply to your child:

Asthma or breathing problems

Allergies (food, medication, environmental)

Diabetes

Frequent ear infections

Seizures or neurological concerns

Developmental delays

Behavioral/mental health concerns

Heart condition

Immunodeficiency

Gastrointestinal issues

Sleep problems

Other chronic illnesses:

Has your child had any surgeries or hospitalizations?

Yes

No

Does your child see any specialists?

Yes

No

Is your child up-to-date on vaccines?

Yes

No

Unsure

Phone

(###)

###

####

Is your child currently in school or daycare?

Yes

No

Any concerns with learning, behavior, speech, or social skills?

Yes

No

I confirm that the information provided is complete and accurate.

I understand that MedMembership provides virtual pediatric care through a monthly

I understand that services are provided via telemedicine and are not a substitute for emergency or in-person care.

I give permission for MedMembership providers to evaluate and treat my child via virtual visits.

I understand that any additional lab or prescription costs will be communicated in advance.