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Untitled Document
Kidcheck
About Developmental Stages Start the Process Pediatric Services
Heartspring Kidcheck

To register your child for KidCheck, please fill out the form below. Your contact information will be forwarded to the Heartspring Pediatric Services Intake Coordinator. You will receive screening materials in the mail within 5 business days.

Register for KidCheck (*Denotes a required field)
Parent First Name
 *
Parent Last Name
 *
Street Address
 *
City
 *
State
 *
Zip
 *
Email
 *
Phone
 *
Child's name
 *
Child's gender

*
Child's Date of Birth
 Month  Day  Year *
Was your child born prematurely?
  *
If yes, how many weeks at delivery date?
(i.e. child born at 37 weeks)
 
Can we add you to our eNewsletter mailing list? Yes     info
 

 

A Service of Heartspring Pediatric Services
www.heartspring.org/kidcheck
8700 East 29th Street North Wichita, KS 67226
316.634.8710  800.835.1043
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