Registration Form

Patient's Full Legal Name

(Last, First, Middle)

Date of Birth

Sex

Primary language

Ethnicity/Race

Mother's Name

(Last, First)

Date of Birth

Social Security

Home Address

City

State

Zip

Primary Phone

Secondary Phone

Work Phone

Occupation

Employer

Email Address

Father's Name

(Last, First)

Date of Birth

Social Security

Home Address

City

State

Zip

Primary Phone

Secondary Phone

Work Phone

Occupation

Employer

Email Address

Preferred contact method

Medical Issues

Primary Phone

Secondary Phone

Text

General Issues

Primary Phone

Secondary Phone

Text

Reminders

Primary Phone

Secondary Phone

Text

Referred by

Children's first and last names and birthdays (oldest to youngest)

Child's first and last name

Bithdate

Child's first and last name

Bithdate

Add new row

Emergency Contact Name (someone other than above)

Relationship

Home Phone

Cell Phone

Medical Insurance Information

Primary Insurance

ID#

Group#

Insurance Phone#

Subscriber's Name

Subscriber's Date of Birth

Subscriber's Address

Secondary Insurance

ID#

Group#

Insurance Phone#

Subscriber's Name

Subscriber's Date of Birth

Subscriber's Address

Financial Agreements

Our policy is to collect all co-payments, deductibles, and non-covered benefits in full at the time services are rendered. If at any time you begin to experience a financial hardship, please ask to discuss reasonable payment arrangements with our financial office before services are rendered. If outside collection services become necessary the undersigned agrees to pay all reasonable service charges. I authorize release of any medical information necessary to process my child/children's insurance claims.

Signature

Relationship

Date

In the event that my child/children should require medical and/or surgical treatment and I am unavailable to bring my child/children to Children's Medical Group I grant authority to Children's Medical Group to administer medical treatment to my child/children as they deem necessary. In addition, I grant authority to the person(s) listed below to seek medical treatment for my child/children as they deem necessary, including signing for and approving any and all recommended lab tests, vaccines and other injectable medication.

Name

Phone Number

Address

Signature

Relationship

Date

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