New Patient Packet

Please correct the errors described below.

Patient Information



Emergency Contact (Other than Parent)

Please list all persons who may call for medical advice or bring your child to the office for treatment. These individuals must show ID at the time of the visit. If someone other than these persons bring your child in, we will have to contact you for a one time verbal over the phone for your child to be seen. If we are unable to reach you, we will only see your child in case of an emergency.

Add Person

Insurance Information

As a courtesy, Seashore Pediatrics will file your insurance provided but cannot guarantee payment. I understand that I am financially responsible for copays/deductibles/etc. for services rendered when charges incur. I hereby authorize Seashore Pediatrics to release all medical information required by my insurance company to file claims for medical benefits. I authorize payment of all applicable benefits directly to Seashore Pediatrics.

Additional Information

Acknowledgement of Notice of Privacy Policy

I acknowledge receipt of the privacy rights with detailed information regarding how Seashore Pediatrics may use and disclose my child's protected health information. I authorize Seashore Pediatrics to release my child's protected health information when contacting me by phone, mail or email I provided on my child's registration form with appointment reminders, test results, account balance information and any other health related information pertaining to my child. This authorization will remain in effect unless revoked in writing.

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.

Initial History


List all family members living in the patient's home

Add Family Member

Current Medical History

Review of Systems and Past Medical History

Does the patient now have or has ever had any of the following:


Are you concerned about the patient's...

If in school, has the patient had...

Maternal and Newborn History


Newborn Check if the patient had any of the following problems:

Family History

If a family member has or has had any of the following problems, check the appropriate box and list the family member: M-Mother F-Father S-Sibling GM-Grandmother GF-Grandfather A-Aunt U-Uncle

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