PATIENT QUESTIONNAIRE

Please list the family members or other persons, i any, whom we may inform about your child's general medical condition and diagnosis (including treatment, payment and health care operations):

Please list the family members of significant others, if any, whom we may inform about medical condition ONLY IN AN EMERGENCY:

Please print the telephone number where you want to receive calls about your appointments, labs and x-ray results, or other health care information if other than your telephone number:

* I am fully aware that a cell phone is not a secure and private line.