New Patient Form

Welcome to West Hills Children's Medical Group,

We have enclosed forms for you to fill out at your convenience. Please fill them out before your child's initial appointment and bring your child's insurance card and immunization record. Well-child exams cannot be performed without immunization records.

We look forward to meeting you and your child(ren).

Please COMPLETELY fill out the following information

Child's Name:

Gender:

Male Female

Date of Birth:

Add new Child's Name:

Mother's Name:

DOB:

Driver's License #:

Home Address:

Street Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Cell Phone:

E-Mail:

Employer's Name and Address:.

Father's Name:

DOB:

Driver's License #:

Home Address

Street Address

City:

State:

Zip Code:

Home Phone:

Work Phone:

Cell Phone:

Employer's Name and Address:

Primary Contact Phone Number (where automated reminders and lab results will be sent)

Would you like us to leave a message on your voice mail ifwe can't reach you?

Yes No

Do we have permission to send you reminders via-e-mail?

Yes No

Language Spoken at Home:

Race:

Ethnicity:

Emergency Contact Name and Phone Number:

(Emergency Contact must be a third party other than parents)

Referred by:

Financial Responsibility:

Mother

Father

Other

If Other selected, Please specify:

Preferred Responsibility Name:

Preferred Responsibility Phone:

Insurance Company:

Insured's Name:

As a courtesy, we will bill your insurance company, but please remember that payment is your obligation regardless of insurance or other third party involvement.

Additional Children Information:

Child's Name:

Gender

Male Female

Date of Birth:

Add new Child's Information

Continuing Consent to Treatment

(Minor or Child or Children)

I, the undersigned, parent or guardian of

a minor child does Hereby consent to any x-ray examination, anesthetic, medical or surgical diagnostic or treatment, and hospital service that may be rendered to said minor, under the general or specific instructions of Scott Calig, M.D ./Susan Salzwedel, P A-C licensed to practice in the state of California, whether such diagnosis or treatment is rendered at the doctor's office or at a hospital licensed by the state of California.

It is understood that this consent is given in advance of any specific diagnosis or treatment being required, but is given in order that said physician/physician assistant may have the opportunity to exercise their best judgment as to the aCtion which may be necessary or required to protect the life and health of said minor child or children.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Parent or Guardian:

Date:

Signature of Witness:

Date:

This consent shall remain effective until revoked by a writing delivered to said physician.

Additional Child or children to be added to the above consent form:

Child's Name:

DOB:

Add new Child's Information

VERIFICATION OF MEDICAL INSURANCE

Name of Insurance Co:

Subscriber's Information:

Name:

Date of Birth:

Social Security Number:

Employer:

Policy Number:

Group Number:

PATIENTS WHO CARRY MEDICAL INSURANCE SHOULD REMEMBER THAT PROFESSIONAL SERVICES ARE RENDERED AND PAYMENT IS THE RESPONSIBILITY OF THE PATIENT/PARENT. INSURANCE BILLING AND ASSISTANCE WITH THE INSURANCE FORMS IS A COURTESY PROVIDED BY OUR OFFICE, HOWEVER, FULL RESPONSIBILITY FOR PAYMENT REMAINS WITH THE PATIENT.

TO AVOID DELAYS AND MISUNDERSTANDING, IT IS IMPORTANT TO LEARN, BEFOREHAND, EXACTLY WHAT BENEFITS YOUR POLICY PROVIDERS AND WHAT TYPE OF COVERAGE YOU HAVE.

ALL DEDUCTIBLES, COPAYMENTS AND COINSUANCE PAYMENTS ARE DUE AND PAYABLE AT THE TIME OF SERVICE UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE PRIOR TO THE MEDICAL SERVICES BEING RENDERED.

YOUR SIGNATURE BELOW INDICATES THAT YOU ARE IN AGREEMENT WITH OUR FINANCIAL RESPONSIBILITY STATEMENT.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Name/Signature:

Date:

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY, THE PRIVACY OF YOUR MEDICAL INFORMATION IF IMPORTANT TO US.

The undersigned Patient or legally authorized representative ("Agent") of the Patient acknowledges that he or she personally received a copy of the Scott Calig, M.D., Inc. Notice of Privacy Policies on the date indicated below:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date:

Information about Agent (attach appropriate documentation):

Agent:

Title:

Pediatric Past Medical History

Child's Name:

Date of Birth:

Birth weight

Pregnancy:

Prenatal Care

Yes No

Maternal Age:

Problems During Pregnancy

Yes No

(If yes, comment)

If Other selected, please specify:

Birth Site:

Hospital

Home

Other

If Other selected, please specify:

Gestation:

(weeks)

Vaginal delivery

Section

Neonatal Problems (First six weeks)

Yes No

If Yes selected, please specify:

Neonatal Problems

Congenital Abnormalities

Breathing

Jaundice

Anemia

Feeding

Infection

Re-hospitalization

Other

If Other selected, please specify:

Adolescent: (13 years -18 years)

Problem with school/family

Smoking

Adolescent Girls:

Sexually active

Any offspring

ETO use

Drug use

Menarche:

Interval:

Pregnancies

Duration:

Medical History:

Allergies to food, environment, medications

Hospitalizations

Surgeries

Injuries, Accidents, Significant Illnesses

Family History:

Mother Alive:

Yes No

Father Alive

Yes No

Number of Siblings (living)

Family history of any serious illnesses/disease?

Yes No

I give permission for the following people to bring my child(ren) in to West Hills Children's Medical Group for treatment/physicals.

Child(ren) Name:

DOB:

Add Child's Information

People allowed to bring my child(ren) to West Hills Children's Medical Group:

Name:

Relationship

Add Name

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Parent Signature:

Date:

Your information will be encrypted.