Welcome to Prospect Pediatrics PA

At Prospect Pediatrics, we provide excellent health care for our patients from infancy through age 21years, in a child friendly relaxed atmosphere designed to make children and family members feel at home and safe. There is continuity of care of your child - the same doctor sees your child each visit.

MISSION STATEMENT:
At Prospect Pediatrics, Our goal is to provide an exceptional quality, comprehensive healthcare for our patients in a compassionate and respectful manner. We pledge to take care of the whole child in the context of his/her family, school and community in the highest ethical and professional level. We take that commitment serious . We feel privileged to be part of your child's life.

-At prospect Pediatrics, we listen while you talk
-Every question that you care about is important to us.
-We provide personalized care
-We simply care.

NEW JERSEY IMMUNIZATION INFORMATION SYSTEM (NJIIS)

CONSENT TO PARTICIPATE

RETAIN A COPY OF THIS FORM IN THE MEDICAL RECORD

REGISTRANT INFORMATION

Registrant Name (Print):
Date of Birth:
Country of Birth:
Name of Primary Health Care Provider:

PARENT/GUARDIAN INFORMATION

Name (Print):
Address :
City , State, Zip Code :
Relationship to Registrant:
I have received information about the New Jersey Immunization Information System (NJIIS) and understand that the purpose
of this program is to help remind me when my/my child's immunizations are due and to keep a central record of my/my child's immunization history.

I understand that the medical information in the NJIIS may be shared with authorized health care providers, schools,licensed child care centers. colleges, public health agencies, health insurance companies, and others as permitted by New Jersey Law at N.J.SA 26:4-131 et seq. and rules at N.J.A.C. 8:57 -3.

I understand that I can get a copy of my/my child's record from my primary heatth care provider, my local health department,
or the New Jersey Department of Health (NJDOH). The NJDOH may be contacted at the website or telephone number
listed above.
There is no cost to participate in this program.
 Yes No

Signature of Registrant (or Parent/Guardian , IF Registrant under 18 Years of Age)
Date
Name of NJIIS Enrollment Site:
Registry ID Number:
Medical Record Number:
 


Address
163 Belleville Avenue Belleville, NJ 07109

Telephone
973-302-4644

Fax
973.528.2242