Patient Registration

PEDIATRICS

Child’s Name:

Date of Birth:

Sex:

Male Female

Address: (Number and street)

City:

State:

Zip:

Email address

Race:

American Indian or Alaska Native

Asian

Native Hawaiian or Pacific Islander

Black or African American

White

Hispanic

Other Race

Refused to Report

Ethnicity:

Hispanic or Latin Not Hispanic or Latin Refused to Report

Parent (or Guardian):

Address: (if different than child’s)

Date of Birth:

Parent (or Guardian):

Address: (if different than child’s)

Date of Birth:

Siblings:

Name:

Add sibling(s)

Best Number to Reach You:

Number:

Please select:

Home Cell Work

Owner:

Mom Dad Patient

Add another number

Emergency Contact (other than child's parents)

Name:

Address:

Phone:

Preferred Pharmacy

Name:

Address:

Patient agrees to release of prescription history from pharmacy

Yes No

Consent for Treatment of a Minor

This is to authorize and consent to any necessary or routine medical or surgical treatment including examination, injection, immunizations and/or diagnostic procedures, including X-ray or lab tests. I understand that only myself or those listed below will have the authority to authorize treatment

Name:

Relationship to Patient:

Add another authorized person(s)

Any person bringing the patient in for treatment not listed above must have a letter of consent from me or treatment could be refused or delayed. I understand that efforts will be made to contact me prior to the rendering of treatment, but that medical treatment will not be withheld if I cannot be reached.

Assignment of Benefits

I authorize direct payment of surgical/medical benefits to Mark G. Gilchrist, MD, LLC for services rendered by him or any health care provider working in this office. I understand, and agree that I am financially responsible for any balance not covered by my insurance and agree to pay the balance.

Authorization to Leave Messages

I agree to allow your office to leave messages on my answering machine/voice mail in reference to items that assist in carrying out the care and treatment of my child including appointment reminders, insurance items and normal lab and X-ray results.

Yes No

This authorization will remain in effect unless so designated, in writing, until the child is no longer a patient of this practice.

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.

Parent/Guardian Signature:

Name:

Files

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