The Children's Clinic Patient Information

Child’s First Name:

Middle Name:

Last Name:

Gender:

Male Female

Child’s Date of Birth:

Place of Birth:

Child’s Birth Weight:

Mother’s First Name:

Middle Name:

Last Name:

P.O. Box:

Street Address / House No:

Home Phone:

Work Phone (with Ext.):

Cell Phone:

E-mail address:

Date of Birth:

Place of Employment:

Insurance Company (If child is /will be enrolled):

Group / Policy Number:

ID/Certificate Number:

Is Mom the policy holder?

Yes No

Father’s First Name:

Middle Name:

Last Name:

P.O. Box:

Street Address / House No:

Home Phone:

Work Phone (with Ext.):

Cell Phone:

E-mail address:

Date of Birth:

Place of Employment:

Insurance Company (If child is /will be enrolled):

Group/Policy Number:

ID/Certificate Number:

Is Dad the policy holder?

Yes No

Additional Patient Information

Pre-Natal Complications:

Allergies:

Hospitalization:

Family History:

Current Medications:

Child lives with:

Both Parents Mother Father Other

Other:

Name/ age of other siblings:

Name:

Age:

Add Sibling

Name of person who referred you:

Phone No: