New Patient Registration Forms

Country Creek Pediatrics builds strong relationships with parents, children, schools and community. We only treat your children with evidence based, medically sound and proven methods. We have the expertise and experience to assist your family in staying healthy mentally and physically.

Dr. Samuels and her staff are here to provide a comfortable and caring atmosphere for your child during all stages of life, from infancy through age 21. It's just our better way to provide better care. We're excited to serve your family!

 
 
Our Patient Portal is available 24 hours a day, 7 days a week for you to communicate with
Dr. Samuels and Office Staff for appointment requests and chart inquiries with responses in less than 48 hours.
 
You'll find forms for New Patients, Annual Exams, Sports Physicals, Release of Records, Consent for Treatment and Medication Administration in School, ADHD Questionnaire, and Asthma. Please contact us if you require a special form to be filled out. Forms will be completed within 48 hours and is available for pick up or mailing 48 hours after the form is received. 

Call to schedule your appointment with Country Creek Pediatrics today at 248.289.7400.