New Patient Paperwork

Add another child

Mailing Address:

Primary Phone Number:

Pharmacy:

Mother's Name:

DOB:

Relationship to Patient:

Biological Relationship:

Address (if different):

City/State/Zip

Home Phone:

Cell Phone:

Lives with patient:

Yes No

Father's Name:

DOB:

Relationship to Patient:

Biological Relationship:

Address (if different):

City/State/Zip:

Home Phone:

Cell Phone:

Lives with patient:

Yes No

Email:

Additional Questions:

Who should receive billing statements:

Provide address if different from patient:

May all Contacts have access to Patient records?

Primary Insurance:

Policy Holder's Name:

Date of Birth:

Policy Holder's Sex:

Insurance Carrier:

ID#:

Employer:

Secondary Insurance:

Policy Holder's Name:

Date of Birth:

Policy Holder's Sex:

Insurance Carrier:

ID#:

If parents are divorced or separated please fill out this section:

Who has custody:

Are there any legal restriction that would restrict the non-custodial parent from consenting to medical treatment for the child or from obtaining information about the child’s medical treatment?

Yes No

If yes please explain and provide a copy of any legal paperwork that supports this restriction.

Emergency Contacts, Other than parents: Name and Relationship

Add Another Contact

Authorization and Release

I authorize release of my information concerning my child’s health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits, otherwise payable to me, directly to the doctor.

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 of Parent or Guardian

Date:

Your information will be encrypted.