Patient Registration Form

Please correct the errors described below.

Main Office
3124 Blue Ridge Road, Suite 102
Raleigh, NC 27612
Office Number: (919) 782‐0021

Brier Creek Office
10208 Cerny Street, Suite 104
Raleigh, NC 27617
Office Number: (919) 226‐0662

MOTHER/LEGAL GUARDIAN

FATHER/LEGAL GUARDIAN

*(Please provide legal documentation for any alternative custody arrangements.)

EMERGENCY CONTACT (Other Than Parent)

INSURANCE INFORMATION

ADDITIONAL INFORMATION

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.

Initial History Questionnaire

SOCIAL HISTORY

Please list those living in the child’s home:

Add new information

If both parents are not living together, who has custody?

BIRTH HISTORY of your child

PAST MEDICAL HISTORY

FAMILY HISTORY

Any family members (parents, siblings, grandparents, aunts or uncles only) have these?

REVIEW OF SYSTEMS

Has your child had any problems with or do you have concerns with any of the following:

Thank you for your time filling out this form. Please sign below stating to the best of your knowledge the above information is correct.

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.

I have reviewed the above information with the parent/guardian.

Your information will be encrypted.

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