New Patient Registration Form

Last Name:

First Name:

MI:

D.O.B:

Sex:

Primary Language:

Ethnicity:

Hispanic Non-hispanic Unknown

Race:

Asian

Black

Hawaiian

White

Primary Address:

City:

State:

Zip Code:

Primary Phone:

Day Phone:

Cell Phone:

Home Email Address:

Referred By:

Hospital/OB:

PAL Website:

Ins. Co.:

Other (name):

Already Est:

Primary Contact:

Name:

Relationship to Patient:

Cell Phone:

Daytime Phone:

Date of Birth:

Social Security #:

For Family Medical History Reasons: Is this contact genetically related to the Child?

Yes No

Lives with patient? – if No please indicate mailing address

Yes No

Street Address:

City:

State:

Zip Code:

We are pleased to provide a Patient Portal in partnership with our electronic medical records provider, Office Practicum for the exclusive use of established patients. The Patient Portal is designed to enhance patient – physician communication.

Please provide your home email address as your username, a temporary password will be provided to you.

At PAL, we strive to clearly and efficiently communicate with our families. Please initial to give PAL permission to communicate via text, email or leave a voicemail.

PAL may send text messages regarding my child(ren) to the above listed cell phone number

PAL may send an email messages regarding my child(ren) to the above listed email addres

PAL may leave a voicemail regarding my child(ren) at the above listed cell phone number

Secondary Contact:

Name:

Relationship to Patient:

Cell Phone:

Day Phone:

Date of Birth:

Social Security #:

Email Address:

At PAL, we strive to clearly and efficiently communicate with our families. Please initial to give PAL permission to communicate via text, email or leave a voicemail.

PAL may send text messages regarding my child(ren) to the above listed cell phone number

PAL may send an email messages regarding my child(ren) to the above listed email addres

PAL may leave a voicemail regarding my child(ren) at the above listed cell phone number

For Family Medical History Reasons: Is this contact genetically related to the Child?

Yes No

Lives with patient? – if No please indicate mailing address

Yes No

Street Address:

City:

State:

Zip Code:

Insurance:

Policy Holder’s Name:

Policy Holder’s Birth Date:

Policy Holder’s Sex:

Male Female

Insurance Name:

ID#:

Group #:

Who should receive billing statements?

Name:

Relationship:

PLEASE PROVIDE ADDRESS IF DIFFERENT FROM THE PRIMARY OR SECONDARY CONTACT:

(Street or PO Box):

(City):

(State):

(Zip):

May all contacts have access to the patient’s records?

Yes No

If no, please indicate who may not have access:

If parents are divorced or separated please fill out this section:

Who has custody?

Are there any legal restrictions that would restrict the non-custodial parent from consenting to medical treatment for the child or from obtaining information about the child’s medical treatment?

Yes No

If yes, please explain and provide a copy of any legal paperwork that supports this restriction. This documentation must be scanned into the patient(s) chart.

Upload any legal paperwork here

Add file

Please upload a file

Emergency Contacts, other than parents: Name & Relationship

I GIVE PERMISSION FOR THE FOLLOWING PERSON(S) TO ACCOMPANY MY CHILD FOR MEDICAL TREATMENT AND TO MAKE MEDICAL DECISIONS IN MY ABSENCE:

Add emergency contact

I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO PEDIATRIC ASSOCIATES OF LAWRENCEVILLE, LLC AND I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS INSURANCE CLAIMS. I VOLUNTARILY CONSENT TO EXAMINATION AND TREATMENT OF MYSELF/OR MY DEPENDENTS. I WILL BE RESPONSIBLE FOR THE FULL AMOUNT OF THE CHARGES EXCEPT THOSE UNDER THE CONTRACTUAL ARRANGEMENTS WITH CERTAIN INSURERS OF PEDIATRIC ASSOCIATES OF LAWRENCEVILLE, LLC.

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 Patient, Parent or Guardian:

Date:

Relationship to Patient:

Your information will be encrypted.