New Patient Form

FAMILY INFORMATION

Date Completed:

Thank you for choosing our office. In order to serve you properly, we need the following information.Please PRINT and fill out this form completely.

Parent’s Name:

Street Address:

City:

State:

Zip:

Primary Phone Number:

Primary E-mail Address:

Referred by:

Preferred method for appointment reminder (please enter number or email):

Text:

Email:

Phone:

CHILDREN

(please fill out sex according to insurance)

Add child

PARENT

Add new row

Parent or Guardian (if applies):

Home Number:

Cell Number:

OTHER PHONE NUMBERS

Caretaker Name:

Phone Number:

Day Care Name:

Phone Number:

Pharmacy Name:

Phone Number:

INSURANCE INFORMATION:

Primary Insurance Policy Holder’s Name:

Primary Insurance Policy Holder’s DOB:

Insurance Company:

ID Number:

Group Number:

Deductible Amount:

Co-Pay Amount:

ATTESTATION:

Parents are expected to attend all wellness visits until patients reach the age of 18.

During the first 3 years of life, we see infants for routine well childcare at:

1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 9 months, 12 months, 15 months, 18months, 2 Years, 2 ½ years, 3 years, and annually thereafter.

Please verify that your insurance company provides full coverage for these visits prior to the visit.

If it is determined that I am not eligible for coverage, I understand that I will be responsible for payment of all services provided.

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

Signature: (Parent or Legal Guardian)

Date:

Pediatrics on Hudson follows the immunization schedule set forth by the American Academy of Pediatrics. Please refer to www.aap.org for details. We firmly believe in the effectiveness of vaccines to prevent serious illness and that they are crucial to every child’s health. If you choose not to vaccinate your child, we ask you to find a different pediatric practice to care for your child.

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

Signature: (Parent or Legal Guardian)

Date:

Your information will be encrypted.