New Patient Form

Child’s Full Name:

Name you wish us to use:

DOB:

Gender:

Male Female

Social Security #:

Birthplace/Hospital:

Primary Pharmacy:

City:

Pharmacy Phone #:

Child lives with:

Both Parents

Mother

Father

Other

If other, specify:

Race:

African American or Black

American Indian/Alaska Native

Asian

Caucasian/White

Native Hawaiian or Pacific Islander

Multi-Racial or Other

Unknown

Declined

Ethnicity:

Hispanic

Not Hispanic

Declined

Unknown

Please list all other siblings (seen at this clinic) you want on this account:

Child’s Full Name:

DOB:

Gender:

Male Female

Add new row for another sibling

Mother’s Information

RESPONSIBLE FOR PAYMENT/GUARANTOR

Initial:

Full Name:

DOB:

Social Security #:

Mother’s Maiden Name:

Employer:

Address:

City:

State:

Zip:

Father’s Information

RESPONSIBLE FOR PAYMENT/GUARANTOR

Initial:

Full Name:

DOB:

Social Security #:

Address:

City:

State:

Zip:

Preferred primary contact number:

Home Work Cell

Home:

Work:

Cell:

Employer:

Emergency Contact:

(not in household)

Relationship to child:

Phone:

Primary Insurance

(The only insurance we file secondary is BCBS. Please give your primary and secondary card to the receptionist)

Insured’s Name:

DOB:

SS#:

Relation to Patient:

Insurance Co:

Insurance ID #:

Group #:

Ins Eff. Date:

Deductible $:

Co-pay for OV $:

Co-pay for labs, shots, etc. $:

Assignment of Benefits

I hereby authorize payment directly to The Children’s Clinic, PLLC for all insurance benefits otherwise payable to me for services rendered. I certify that the information I have reported to The Children’s Clinic, PLLC with regard to my insurance is correct. I also authorize the release of any necessary information, including medical information, if requested by my insurance company. I permit a copy of this authorization to be used in such instances. I authorize the use of this signature on all insurance submissions. I understand that I am financially responsible for all charges, whether or not paid by insurance and for all services rendered on my behalf or my dependents.

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.

Responsible Party or Patient (if over the age of 18):

Date:

How did you hear about our office?

Website/Internet Search

Friend

Physician

Yellow Pages

Parents & Kids or other magazine

Other

If other, specify:

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