Pediatric Information Form

Patient Information

Name of Patient

Date

Home Address

City

State

Zipcode

Home Telephone

Alternate Telephone

Date of Birth

SSN

Parent's Names

Mom's Work #

Cellular

Dad's Work #

Cellular

Person Financially Responsible for Patient

Emergency Contact

Relationship

Telephone

Whom May We Thank for Referring You

PRIMARY INSURANCE

Add Secondary Insurance

Authorization For Treatment

I authorize Dr. Berry, Monde-Matthews, or Tice to provide medical treatment for my child

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

Signature

Relationship to Patient

Assignment of Insurance Benefits

I request that payment of authorized insurance benefits be made to me or on my behalf to My Kid's Doc - Southfield, PLLC for any services furnished to me by that provider. I authorize any holder of medical information about me to release to the

and its agents any information needed to determine benefits payable for related services. This authorization is in effect for my lifetime, or until I choose to revoke it.

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

Signed

Date

Patient Demographics Questionnaire

Patient Name

Date of Birth

Account # (office use only)

We are asking for your race and ethnicity because some people have higher risks of developing certain diseases.

We will keep this information confidential (private) and will update it in your medical record. This information will assist us in continuing to provide you with the best health care.

Please fill in the information below. We greatly appreciate your participation.

1. Race - please mark which best describes you.

White/Caucasian

Black/African American

American Indian or Alaska Native

Asian

Native Hawaiian

Other Pacific Islander

More than one race

I prefer not to answer

2. Are you of Hispanic Origin?

Yes

I prefer not to answer

3. Please indicate your preferred spoken language

I prefer not to answer

Please indicate

4. Email address (please print)

Electronic Perscriptions Form

Date completed

Patient Name

Patient's Date of Birth

Patient's Phone Number

Patient's Zip Code

Medication Allergies and Reactions

Pharmacy Name

Pharmacy City and Cross Streets

If you have other children, you may include them below

Name

Date of Birth

Medication Allergies/Reactions

Third Party Consent for Treatment and Examination

Add Patient Name

The parent/guardian of the above named children give permission for

to seek medical care and treatment for him/her/them

I can be reached by phone

I can be reached by email

I can be reached by fax

My signature below certifies my consent for examination and treatment of my children.

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

Signature of Parent and / or Guardian

Date

Witness Signature

Date

This consent is valid for one year from date of signature.

Your information will be encrypted.