Business Form

• Pediatric care on your schedule
• Walk-in convenience
• For all simple illness or injury
• Seven days a week
• No appointment needed
• Available at all locations

Locations
Click on location for details

Brooklyn Park

Calhoun

Maple Grove

Plymouth

Rogers

PIP Hours
By Appointment 
Monday through Friday 
at all offices 8:00 am to 5:00 pm

ReadyCare Hours
Walk-ins Welcome
Monday through Friday at all offices 
8:00 am to 5:00 pm

Monday through Thursday Evenings 
Maple Grove 5:00 pm to 8:00 pm

Saturday and Sunday 
Maple Grove 8:30 am to 12:30 pm

Please use this form only for account questions. If you need medical advice or would like to make an appointment, please call the clinic location where your children are seen.

Partners in Pediatrics account number, (located on the upper right of your statement, 8 characters) *

Patient Account Information

Patient's First and Last Name *

Patient's Birthdate *

Parent's First and Last Name *

Contact Phone Number *

Alternative Contact Phone Number

E-mail address *

Reporting an address change? Complete below

Effective date of change

New address

New city

State

ZIP

Phone 1

Phone 2

Reporting an insurance change? Complete below

Effective date of change

New insurance company name

ID#

Group#

Policyholder’s Name

Policyholder’s Place of Employment

Policyholder’s Birthdate

Is this coverage primary or secondary

Does this coverage replace the information we have in our records, or is it in addition to our current information?

How can we help you? Please detail your account question(s) in the box below. We will contact you by phone or by e-mail within the next two business days.

*) Required fields

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Patient Account Information

Reporting an address change? Complete below

Reporting an insurance change? Complete below