Patient Registration Forms - English

Patient Information

Last name:

First name:

Middle:

Date of birth:

Sex:

Male Female

Social Security Number:

Phone:

Address:

City:

State:

Zip:

Race:

Caucasian

African/American

Native American/Alaskan

Pacific Islander

Other

If Other, please specify:

Ethnicity:

Non-Hispanic Hispanic

Checkbox list

English

Spanish

Russian

Other

If Other, please specify:

Preferred provider at Skagit Pediatrics:

Hospital:

Skagit

Island

Providence

Home Birth

Other

If Other, please specify:

Emergency contact (not living with you):

Phone:

Parent Information

Parent info #1

Please select:

Mother Father Other

If Other, please specify:

Name:

Date of birth:

SSN:

Home phone:

Cell phone:

Work phone:

Other:

Home address (IF DIFFERENT from patient) :

City:

State:

Zip:

Marital Status:

Single Married Divorced Other

If Other, please specify:

Parent info #2

Please select:

Mother Father Other

If Other, please specify:

Name:

Date of birth:

SSN:

Home phone:

Cell phone:

Work phone:

Other:

Home address (IF DIFFERENT from patient) :

City:

State:

Zip:

Marital Status:

Single Married Divorced Other

If Other, please specify:

Insurance Information * Please Give Cards to the Receptionist

Primary Insurance

Primary insurance:

Policy holder name:

DOB:

SS#:

Policy #:

Group #:

Secondary Insurance

Secondary insurance:

Policy holder name:

DOB:

SS#:

Policy #:

Group #:

Preferred e-mail:

Please list all children in the family

Add child

Consent for care and treatment

I agree to administration of medical treatment by the physicians/ARNPs of Skagit Pediatrics and their assistants for care of the above listed children. I understand these procedures will be explained to me in advance.

I hereby authorize my insurance benefits to be paid directly to the physician and I am financially responsible for non-covered services. I also authorize the release of any information required in the processing of claims.

I have read and understood the terms of this agreement. I am the proper person to give this consent.

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.

Name:

Relationship to patient:

Date:

This agreement is void and unenforceable, and I am under no obligation to pay the provider, if my medical program covers the services listed above or if the provider fails to satisfy DSHS conditions of payment as described under WAC 388-87-010(6)

Your information will be encrypted.

Patient Registration Forms - English

Patient Information

Parent Information

Parent info #1

Parent info #2

Insurance Information ***** Please Give Cards to the Receptionist****

Primary Insurance

Secondary Insurance

Please list all children in the family

Consent for care and treatment

Insurance Information * Please Give Cards to the Receptionist