Join Us!

Thank you for choosing Commonwealth Pediatrics as your child's medical home. We are honored to have you as part of our team. Please take a moment to complete the form below. You will be contacted within two business days with additional information about how to transfer your child's medical records and schedule a first appointment with Dr. Lock or Dr. Espinosa. We look forward to meeting you at our office in Stoneham!

Patient Name *

Patient Name

First Name

Last Name

Patient Date of Birth *

Patient Date of Birth

YYYY

Parent Name *

Parent Name

First Name

Last Name

Guarantor (person who carries the insurance) *

Guarantor (person who carries the insurance)

First Name

Last Name

Insurance *

Primary Phone *

Primary Phone

(###)

###

####

Secondary Phone

(###)

###

####

Email Address *

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Doctor *

How did you hear about us?

Please give us any additional information that you feel would be helpful.

If you have multiple children that you would like to register, feel free to provide their names and dates of birth in this section.