Patient Information (18 and Older)

Name

Date of Birth

Social Security #

Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

Employer

Occupation

Email address

If other, Please specify

If other, Specify

Whom do you live with?

Self

Spouse / Partner

Both Parents

Mother Only

Father Only

Mother / Step - Father

Father / Step - Mother

Other (Specify)

1. General contact method (Nurse/Doctor/Staff)

Home Phone

Your Cell

Other

If Other, Please specify

2. Portal Internet electronic contact method

Text to your cell

Your email

Other

If Other, Please specify

3. Appointment Reminders

Home phone

Your Email

Other

If Other, Please specify

EMERGENCY CONTACT INFORMATION

Additional Contact

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

Date

PROTECTED HEALTH INFORMATION CONSENT

By signing below, I understand that if I so choose, the individuals or agencies I have listed will be given access to my PROTECTED HEALTH INFORMATION from Associated Pediatricians, LLC.

CHOOSE FROM THE FOLLOWING:

I do not wish to designate a personal healthcare representative with respect to my protected health information at this time.

I hereby grant permission to Associated Pediatricians, LLC to disclose my protected health information to those names listed below.

I hereby by grant permission to Associated Pediatricians, LLC to disclose to disclose my protected health information and give access to my patient portal account to those names listed below.

Name

Relationship to Patient

Additional Name

Patient Name / Signature

Date

Responsible Party Signature

Date

Your information will be encrypted.