Patient Registration

Northwest Suburban Pediatrics

(Please fill in all fields completely)

Patient Information:

Child's Full Legal Name:

Last Name:

First Name:

Middle Initial:

Date of Birth:

Sex

Male Female

Other Children in the family

Child's Street Address:

City:

State:

Zip Code:

Preferred # to reach you (please label with name)

Phone #:

Name:

Type

Home Cell Work

Add Another Phone Number

This will be how we reach you. May we leave a message on this phone?

Yes No

Parent's Email Address (please label name):

Name:

May we contact you via email?

Yes No

Race: (Please Choose)

American Indian or Alaska Native Asian African American White Native Hawaiian and other Pacific Islander

Ethnic Group: (Please Choose)

Hispanic Non·Hispanic

Language:

English Other

If you choose Other, Please specify:

Emergency Contacts:

Parent Name:

Sex

Male Female

Date of Birth

Home Address (if different from above)

Address:

City:

State:

Zip:

Add Another Parent Contact

Who may we thank for referring you to our practice:

Birth Hospital:

Insurance Information:

Subscriber Name:

Insurance Company:

ID#:

Group #:

Phone #:

Secondary Insurance Company:

ID#:

Group #:

Phone #:

Subscriber/Guarantor·- Person financially responsible:

Employer:

Employer Phone #:

Permission to Treat:
I give permission to Northwest Suburban Pediatrics, S.C. to render treatment to my minor children

DISCLAIMER: 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:

Relationship:

Date:

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