Patient Registration Form

Family Last Name:

Mother's Information (Or Guardian)

Name:

DOB:

Address:

City:

ST:

Zip:

(If different than father's address)

Primary Phone:

Home Cell Work

Primary Phone #:

Secondary Phone:

Home Cell Work

Secondary Phone #:

E Mail Address:

Occupation:

Employer:

Phone:

Address:

City:

ST:

Zip:

Marital Status:

Father's Information (Or Guardian)

Name:

DOB:

Address:

City:

ST:

Zip:

(If different than mother's address)

Primary Phone:

Home Cell Work

Primary Phone #:

Secondary Phone:

Home Cell Work

Secondary Phone #:

E Mail Address:

Occupation:

Employer:

Phone:

Address:

City:

ST:

Zip:

Marital Status:

If divorced, which address is the child's (children's) primary address:

Mother Father Guardian

INSURANCE

Cardholder 's Name:

Primary Insurance:

Group Number:

Cardholder ID #:

INSURANCE

Cardholder 's Name:

Secondary Insurance:

Group Number:

Cardholder ID #:

LIST ALL CHILDREN IN FAMILY WHO ARE PATIENTS IN OUR OFFICE:

Add another child

Emergency Contact: (Not Parent)

Name:

Relationship:

Phone:

Address:

City:

ST:

Zip:

Name or Preferred Pharmacy:

City:

Intersections:

Authorization to Treat: There may be occasions when a parent (guardian) is not available to bring your child(ren) to our office. Your signature below allows us to provide care for your child(ren) in your absence. Otherwise, we need written permission prior to caring for your child(ren) for each occurrence.

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

Signature or Parent/Guardian:

Date:

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