Patient Demographic Information

Last Name:

First Name:

Middle:

Suffix:

Nickname:

Date of Birth:

Sex:

F M

If other language, specify:

Add new row for another child

Home Info

Street Address:

Apt #:

P. O. Box:

City:

State:

Zip:

Primary Phone #:

Select one:

Home Cell

Second Phone #:

Select one:

Home Cell

Mother’s Info

Last Name:

First Name:

Address:

Social Security #:

Date of Birth:

Cell #:

Work #:

Occupation:

Father’s Info

Last Name:

First Name:

Address:

Social Security #:

Date of Birth:

Cell #:

Work #:

Occupation:

Authorize

I authorize the persons listed below permission to accompany my child to the office and receive medical information pertaining to my child’s care. If you give permission for the persons listed to authorize vaccine administration for your child/children, please indicate below.

Name:

Vaccine - YES

Relationship to Child:

Phone:

Name:

Vaccine - YES

Relationship to Child:

Phone:

Privacy Notice

The federal Law requires that we make every effort to inform you of your rights related to your personal health information. Please check only one below.

Yes, I have read or had explained to me by this office the Notice of Privacy Practices & I wish to continue my care with Ambler Pediatrics under said terms.

No, I have not read this office’s Notice of Privacy Practices but, I was given the opportunity to read it upfront and declined. I wish to continue my care with Ambler Pediatrics under said terms.

Consent to Leave

If we are unable to speak with you directly, we may need to leave a voice mail/answering machine message or a message with a family member or others who answer your telephone. This message may include detailed information about your child’s condition or treatment, such as test results or the scheduling of procedures. Please check one:

Yes, you may leave detailed messages.

Leave messages at:

No, DO NOT leave detailed messages, generic messages only.

E-Mail

Can we email you reminders for well visits?

Yes No

IF YES, email me at:

Pharmacy

Please list your preferred Pharmacy Name, Address & Phone # below:

Financial Assignment & Medical Release

I authorize Ambler Pediatrics to bill, receive, release and exchange information with my child’s insurance company, as well as authorize my insurance company to pay the proceeds of any benefits directly to Ambler Pediatrics.

I understand that I am ultimately responsible to know what my insurance will cover and to pay for any denied services.

I understand that if I do not pay my balance within 60 days, a 1.50% service fee will be charged to my account, each month, until the account is paid in full.

I acknowledge that copays/deductibles/coinsurances are due at the time of service, regardless of who brings my child to the office. If payment is not made at the time of service, a $12.00 service fee will be charged to our account.

I acknowledge that if I do not give at least 24 hours notice of cancellation, a $25.00 service fee will be charged to our account for each missed appointment.

I certify that the information I furnish is true and correct. I know it is a crime to fill this form with facts I know are false or leave out facts I know are important, and by signing below, I agree to all boxes I checked on this form.

DISCLAIMER: By typing your name(s) 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 #1 Signature:

Relationship to Patient:

Today's Date:

Parent #2 Signature:

Relationship to Patient:

Today's Date:

Your message will be encrypted.