Pediatric Associates of Denham Springs

PATIENT INFORMATION

Date

Patients Name

First

Middle

Last

Preferred Name

Date of Birth

Sex

M F

Patient's Street Address

Race

Dominant Hand

Left Right

Ethnicity

Birthplace/Hospital

PARENT/GUARDIAN INFORMATION

Marital Status of Parents

Married Divorced Separated

IF NOT MARRIED, Who has Custodial Rights

Mother ONLY Father ONLY Both Parents

Others

Father's Name

DOB

Phone

Email Address

Mother's Name

DOB

Phone

Email Address

Emergency Contact

Phone

INSURANCE INFORMATION

Name of Insurance Company

Phone

ID Number

Policy Holder

Date of Birth

Relationship to patient

CONSENT

My signature below authorizes the following person(s) to bring my child in for medical care, pick up prescription/forms, or to discuss my child's medical care.

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✓ I give my permission for Pediatric Associates of Dental Springs to treat my child according to the standards of care within the community & the realm of medical necessity as deemed appropriate by his/her physicians.

✓ I give my permission for Pediatric Associates of Denham Springs to obtain my child's e-med history.

✓ I give my permission for Pediatric Associates of Denham Springs to send text message reminders.

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 / Name of Patient or Authorized Representative

Your information will be encrypted.