Compassion Pediatrics — Patient Check-In

Guardian

Enter the parent/guardian name and the child(ren) name(s).

Parent/Guardian Full Name

Phone Number

Which side of the clinic?

Well Side Sick Side

Select one. Default is Well Side.

Where are you checking in from?

In Office (Waiting Room) In Car

Select one. Default is In Office.

Enter name (0–20 letters). Tap “Add Child” to add more.

Reason for visit (optional)