Patient Registration Form

Add another patient

Insurance Information

Primary Policy

Policy Holder's Name

Policy Holder's Date of Birth:

Policy Holder's SSN:

Insurance Carrier

Group #

Policy ID #

Secondary Policy

Policy Holder's Name

Policy Holder's Date of Birth:

Policy Holder's SSN:

Insurance Carrier

Group #

Policy ID #

Responsible Party

Mother's Name/Guardian

DOB:

Mother's/Guardian Address

Mother's/Guardian Phone #

Email address

Mother/Guardian Employer

Mother/Guardian Work #

Father's Name/Guardian

DOB:

Father's/Guardian Address

Father's/Guardian Phone #

Father/Guardian Employer

Father/Guardian Work #

Email address

**ALL Patient Portal and Statements will be sent via email unless otherwise advised**

Add another emergency contact

If parents are divorced or separated please fill out this section:

Who has primary custody?

Are there any legal restrictions that would restrict the non-custodial parent from consenting to medical treatment for the child or from obtaining information about the child’s medical treatment?

Yes No

If yes, please explain and provide a copy of any legal paperwork that supports this restriction.

The following individuals are able to authorize medical treatment for my child(ren) in my absence:
(If child is 16 and will may drive self and come alone please add his/her name and self as relationship):

Add another authorized persons

CONSENT TO TREATMENT: I hereby authorize Highland Pediatrics or whomever they may designate, to administer treatment to the above named children.

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

Date

Relationship to Patient

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