PEDIATRIC REGISTRATION FORM

CHILD’S FULL NAME

FIRST NAME:

MIDDLE:

LAST NAME:

CHILD’S GENDER

MALE FEMALE

CHILD’S PRIMARY LANGUAGE

ENGLISH SPANISH OTHER

IF OTHER, PLEASE SPECIFY:

CHILD'S DATE OF BIRTH:

PRIMARY HOME ADDRESS:

CITY:

STATE:

ZIP:

EMAIL ADDRESS:

PRIMARY HOME PHONE:

PRIMARY CELL PHONE:

PRIMARY WORK PHONE:

CHILD ETHNICITY:

HISPANIC NON-HISPANIC DECLINE

CHILD RACE:

AMERICAN INDIAN / ALASKA NATIVE ASIAN BLACK OR AFRICAN AMERICAN NATIVE HAWAIIAN OR PACIFIC ISLANDER WHITE OTHER

If Other, please specify::

OTHER SIBLINGS IN /PLEASE LIST

NAME:

DATE OF BIRTH:

Add new name of sibling

MOTHER OR LEGAL GUARDIAN’S INFORMATION

MOTHER/GUARDIAN’S FULL NAME:

MOTHER’S/GUARDIANS MAIDEN NAME:

RELATION TO THE PATIENT (IF APPLICABLE):

MOTHER/GUARDIAN’S DATE OF BIRTH:

MOTHER/GUARDIAN MAILING ADDRESS:

CHECK IF SAME AS CHILD

CITY:

STATE:

ZIP:

MOTHER/GUARDIAN HOME PHONE:

MOTHER/GUARDIAN CELL PHONE:

MOTHER/GUARDIAN EMPLOYER:

MOTHER/GUARDIAN EMPLOYER PHONE #:

MOTHER/GUARDIAN EMAIL:

FATHER OR LEGAL GUARDIAN’S INFORMATION

FATHER/GUARDIAN’S FULL NAME:

CHILD LIVES WITH (SELECT ONE):

MOTHER FATHER BOTH OTHER

IF OTHER, PLEASE SPECIFY:

FATHER/GUARDIAN’S DATE OF BIRTH:

FATHER/GUARDIAN MAILING ADDRESS:

CHECK IF SAME AS CHILD

CITY:

STATE:

ZIP:

FATHER/GUARDIAN HOME PHONE:

FATHER/GUARDIAN CELL PHONE:

FATHER EMPLOYER:

FATHER EMPLOYER PHONE #:

FATHER/GUARDIAN WORK PHONE:

INSURANCE INFORMATION-THIS SECTION MUST BE COMPLETE OR PAYMENT IN FULL IS DUE AT TIME OF SERVICE

NAME OF INSURANCE:

ID #:

PRIMARY HOLDER NAME:

EMERGENCY CONTACT INFORMATION

NAME OF PERSON NOT LIVING WITH YOUR CHILD:

RELATIONSHIP TO CHILD:

EMERGENCY CONTACT’S PHONE NUMBER:

PREFFERED PHARMACY

NAME OF PHARMACY:

ADDRESS OR INTERSECTION:

PHARMACY PHONE NUMBER:

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