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New Patient Checklist

New here? Please start with our new patient consultation form.

New Patient
banner for patient forms


Submit the form and our staff will call you to set up consultation!

Are you a New or Existing Patient?


Preferred Location




First Name
Last Name
Child’s Full Name (if born)
Child’s Date of Birth (if known)
Do you have insurance?


Provide the insurance provider name(s)
Provide your insurance number(s)
Mailing Address
City, State Zip
Primary Phone Number
Your Email
Additional Comments
How did you hear about us?





https://valcourtpediatrics.com/resources/new-patient-checklist/
There has been some error while submitting the form. Please verify all form fields again.

Required Documents

  1. Valid Drivers License or photo ID of Parent/Guardian
  2. Insurance card (Photo, copy, or email accepted)

Insurance Information:
For details on accepted insurance plans and coverage, click here.

Note for Georgia Patients:

Due to state-specific insurance policies,
Georgia patients must have Dr. Yvrose Valcourt or Valcourt Pediatrics listed as their Primary Care Provider (PCP) before being seen.

Patient Forms & Appointment Info

Patient Forms (English and Spanish):

All new patients must complete our New Patient Forms prior to their visit. These can be submitted online or brought to the office.

  1. Click to open the form below.
  2. Fill out directly on your device.
  3. Save the completed form to your phone or computer
  4. Email it to admin@valcourtpediatrics.com
          — or —
    Bring a printed copy to your appointment.
Patient Form PDF

Formulario del Paciente (Español)

At Check-In:

  • Present your photo ID, insurance card, and copay (if required)
  • Arrive 15 minutes early to allow time for verification and processing

Disclaimer:

All patients are required to comply with our intake procedures and office policies. Submission of forms does not guarantee an appointment until confirmed by our staff.

Cash Basis Patients:

We accept patients on a cash basis. Please contact our office for pricing and payment options.

Out-of-State Patients:

If you are coming from outside of Georgia or South Carolina, please bring a copy of your child’s immunization records. We accept records in any format (paper or digital).

Augusta
Main Office

(706) 955-4639
1511 Anthony Rd. Augusta, GA 30904-4821

Aiken

(803) 226-0005
410 Barnwell Ave NW, Aiken, SC 29801

Ridgeland

(843) 645-3232
3191 Argent Blvd, Suite 104, Ridgeland,
SC 29936

Walterboro

(843) 599-9064
124 Medical Park Drive, Walterboro,
SC 29488

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