New Patient Form

Please correct the errors described below.

Patient Registration

WHO TO CONTACT IF WE CAN'T REACH PARENT/GUARDIAN IN AN EMERGENCY?

INSURANCE INFORMATION

The guarantor is responsible for all fees. Fees are due at the time of service. Please read and sign the following Authorization and Assignment.

Insurance Authorization & Assignment

I hereby authorize Ofelia B. Ayuste, M.D.S.C. to furnish information to my insurance company carrier concerning my child or children's illness or treatment. I also hereby assign the Doctor all outstanding payments for medical services rendered to my dependent(s). I UNDERSTAND I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY MY INSURANCE.

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.

Family History

Have any family members had the following:

Past History

Does your child have, or has he/she ever had:

Initial History Questionnaire

Household

Please list all those living in the child's home.

Add new child

Birth History

During pregnancy, did mother

General

Development

If your child is in school:

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