Help us make sure we have the correct contact information by filling out the form below so we can get you setup in our on-lineHIPAA compliant electronic medical interface and get you scheduled right away!

Once this form is submitted it will go to our patient coordination team and they will reach out to you via email within 24 hours to get you set up and scheduled!

Please be on the lookout for the email to come from support@infantacidrefluxsolutions.com Be sure to check your junk or spam folder as sometimes it filters there.

This Form cannot be submitted until the missing fields (labelled below in red) have been filled in

Please note that all fields followed by an asterisk must be filled in.

First Name*

Last Name*

E-Mail Address*

Home Phone*

Your baby's name*

Your baby's date of birth (MM/DD/YYYY)*

I agree to the COPPA Disclaimer*

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