New Patient Form

Patient Registration

Date:

Add additional child

Mailing Address:

Street or PO Box:

Unit or Apartment #:

City:

State & Zip:

Home Phone:

Who lives at this household?

(Please note, this information is being requested to improve intake of your child’s Social History.)

Emergency Contact, other than parents: Name & Relationship

Name:

Relationship:

Phone:

How would you ideally prefer to we contact you regarding (select one):

Recall Notices:

Home Address Home Phone Work Phone Cell Phone Home Email

General Practice Notices:

Home Address Home Phone Cell Phone Home Email

Patient Portal Notifications:

Cell Phone Home Email Work Email

Appointment Reminders:

Home Phone Cell Phone Home Email Work Email Text to Phone

Contact 1 (Primary – will get all reminders):

Name:

Relation to Patient:

Biological Relation to Patient:

(Please note, this information is being requested to improve intake of your child’s Family Medical History.)

Lives with patient?

Yes No

Date of Birth:

Work Phone:

Cell Phone:

Home Email:

Work Email:

Employer:

Occupation:

ADDRESS IF DIFFERENT THAN CHILD:

Contact 2:

Name:

Relation to Patient:

Biological Relation to Patient:

(Please note, this information is being requested to improve intake of your child’s Family Medical History.)

Lives with patient?

Yes No

Date of Birth:

Work Phone:

Cell Phone:

Home Email:

Work Email:

Employer:

Occupation:

ADDRESS IF DIFFERENT THAN CHILD:

Additional Contact Questions:

Who should receive billing statements?

May all contacts have access to the patient’s records electronically?

Yes No

Referred by:

Insurance:

Primary Policy: Policy Holder’s Name:

Date of birth:

Policy Holder’s SSN:

Policy Holder’s Sex:

Male Female

Insurance Carrier:

ID#:

Secondary Policy: Policy Holder’s Name:

Date of birth:

Policy Holder’s SSN:

Policy Holder’s Sex:

Male Female

Insurance Carrier:

ID#:

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

Who has custody?

Are there any legal restrictions 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.

Do your children attend Daycare?

Yes No

Nanny:

Full Time Part Time

Location:

Smokers around child?

Yes No

Smokers around child?

Father

Mother

Brother

Sister

Other

If Other, please specify:

Pets in home?

Yes No

Pets in home?

Dog(s)

Cat(s)

Fish

Birds

Gerbils

Hamster

Other

If Other, please specify:

Guns in home?

Yes No

Guns are kept:

Unloaded Locked Ammunition stored Separately

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