Patient Information Form

Patient Name:

First Name:

Middle:

Today's Date:

DOB:

Sex:

Male Female

Patient Cell Number (if applicable):

Email address

MOTHER/PARENT 1

Name:

First Name:

MI:

Date of Birth:

Social Security #:

Home Address:

City:

State:

Zip:

Select Primary Phone Number:

Home Phone Number Cell Phone Number

Home Phone Number:

Cell Phone Number:

Work Phone Number:

Email address

Employer:

Occupation:

FATHER/PARENT 2

Name:

First Name:

MI:

Date of Birth:

Social Security #:

Home Address:

City:

State:

Zip:

Select Primary Phone Number:

Home Phone Number: Cell Phone Number:

Home Phone Number:

Cell Phone Number:

Work Phone Number:

Email address

Employer:

Occupation:

Emergency Contact:

Relationship:

Phone #:

Click the "Add File" below to Upload a Copy of your insurance:

Add file

Please upload a file

Insurance:

Insured's Name:

Insurance ID Number:

Group Number:

Responsible Party:

The information provided above is complete and accurate to the best of my knowledge. I acknowledge that I have received Cherry Creek Pediatrics’ Notice of Privacy Practices. I have read, fully understand, and agree to all terms set forth in the Office & Financial Policy of Cherry Creek Pediatrics, PC. I assign directly to Cherry Creek Pediatrics all insurance benefits if any, otherwise payable to me for services rendered. I understand that some or all of the services provided may not be covered by insurance for which I may also be billed. I hereby authorize Cherry Creek Pediatrics to release all information necessary for claims administration and evaluation, utilization review, and financial audit. I authorize my child to be treated without me being in attendance.

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

Signature:

Date:

Over 18 years Patient Signature:

Date:

Past Medical History

Is your child currently on any medications?

Yes No

If yes, please explain.

Does your child have any serious or chronic illnesses?

Yes No

If yes, please explain.

Has your child had serious injuries or accidents?

Yes No

If yes, please explain.

Has your child had any surgeries?

Yes No

If yes, please explain.

Has your child ever been hospitalized?

Yes No

If yes, please explain.

Is your child allergic to any medications?

Yes No

If yes, please explain.

Has your child ever had an adverse reaction to a vaccine?

Yes No

If yes, please explain.

Please list any significant family history we should be aware of (i.e., diabetes, asthma, heart issues, thyroid issues, etc):

Add another sibling

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