Request appointment | Winlock Pediatrics LLC

Request an appointment

Important Insurance & Scheduling Information Before you begin, please review these critical items. A. Insurance Our clinic is dedicated to serving Apple Health (Medicaid) families and most commercial insurance plans.

We are NOT in-network with Kaiser Permanente or Tricare. * Do you or your child currently have Kaiser or Tricare as your primary insurance?

Insurance plan and ID number

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

Final Acknowledgment & Signature Next Steps: • Step 1: After you submit this form, you will be placed on our Waitlist. • Step 2: Our office will review your information. If we are able to move forward, we will send you our full intake packet and specialized rating scales. • Step 3: Once ALL rating scales and forms are completed and returned, you will be moved to the "Ready to Schedule" list, and we will contact you to schedule your first (virtual) appointment. * Your signature below indicates: • You are the legal parent or guardian with the authority to make healthcare decisions for this child. • You have read, understood, and agree to the policies and consents contained in this document. • You certify that the information provided is accurate and complete to the best of your knowledge.

I agree

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.