Patient and Family Information Form

Child's Full Name

Date of Birth

Preferred Nickname

Sex (Select One)

Male Female

Add additonal child's information

Address

Cell Phone

Home Phone

May we leave detailed voice messages on the phone numbers listed?

Yes No

May we text you detailed information on your cell phone?

Yes No

E-mail address for Patient Portal:

Pharmacy Name, Address and Phone Number:

Parent/Guardian Information

Parent/Legal Guardian #1:

Date of Birth

Lives With Patient:

Yes No

(If no, please provide address)

Parent/Legal Guardian #2:

Date of Birth

Lives With Patient:

Yes No

(If no, please provide address)

Insurance Information:

Primary Policy

Policy Holder

Secondary Insurance

Policy Holder

Who should receive billing statements?

Emergency Contact Other Than Parent/Guardian:

Name

Phone Number:

Besides parent/guardian(s) listed above, who has permission to bring your child(ren) to Medical Center Pediatrics and consent to treatment?

Name

Relationship to Patient

Other Information

Whom may we thank for referring you to our office?

Race

American Indian or Alaskan Native Asian Black Hawaiian Native or Pacific Islander White

Ethnicity

Hispanic or Latino Not Hispanic or Latino

Languages Spoken:

By signing below, I give my consent for my child(ren) listed to receive treatment by Medical Center Pediatrics, PLLC

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

Signature

Date

Your information will be encrypted.