Ennis Pediatrics - New Patient Form

PATIENT GENERAL INFORMATION

First Name:

Middle Name:

Last Name:

Date of Birth:

Language:

Street Address:

City, State, Zip Code:

Race:

Ethnic Group

PARENT INFORMATION

Father's Name:

Birth Date:

Employer:

Street Address:

City, State, Zip Code:

Home Phone:

Cell Phone:

Work Phone:

E-mail Address:

Mother's Name:

Birth Date:

Employer:

Street Address:

City, State, Zip Code:

Home Phone:

Cell Phone:

Work Phone:

E-mail Address:

EMERGENCY INFORMATION

Emergency Contact Name:

Relationship to Patient:

Home Phone:

Cell Phone:

Work Phone:

PREFERRED PHARMACY

Pharmacy Name and Location:

Pharmacy Phone:

PRIMARY INSURANCE INFORMATION

Name of Insurance Company:

Phone:

Claims Mailing Address:

Name Of Primary Insured Or Policy Owner:

Date of Birth:

Patient ID number:

Policy Number:

Group Number:

Effective Date:

SECONDARY INSURANCE INFORMATION

Name Of Insurance Company:

Phone:

Claims Mailing Address:

Name of Primary Insured or Policy Owner:

Date of Birth:

Patient ID Number:

Policy Number:

Group Number:

Effective Date:

CORRESPONDENCE PREFERENCES

SIBLINGS (Please list any siblings of the patient who are patients at Ennis Pediatrics.)

Name:

Date of Birth:

Add another sibling

PREAUTHORIZATION TO TREAT MINORS

It may be more convenient to have prior authorization in place so that medical care may be delivered directly to minors if a parent or legal guardian cannot be present prior to treatment. This may include but is not limited to, a grandparent, babysitter or family friend. Please be advised that protected patient health information may be shared with the proxy to whom the right to consent has been delegated to facilitate informed decision making.

I authorize Ennis Pediatrics and its personnel to provide medical care to this child in my absence.

Initials:

I do not authorize Ennis Pediatrics to provide medical care in my absence.

Initials:

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