KAP Patient Registration

Address

City

State

Zip

Mother - Parent/Legal Guardian

DOB

SS#

Contact #

Father-Parent/Legal Guardian

DOB

SS#

Cell #

Required by Government Mandate

Language

Race

Ethnicity

Send Statements to

Mom

Dad

Contact Preferences

Dad Cell

Mom Cell

Parent's Marital Status

Married Widowed Divorced Legally separated Other

Insurance Info

Primary Insurance Name

Policy Holder

Id #

Grp#

Policy Holder DOB

Patient's Relationship to Insured

File attachments

Add file

Please upload a file

By signing this form, I attest that I have personally read this form (or had it explained to me) and fully understand and agree to its contents.

Parent/Guardian Signature:

Cell Phone #:

This will be used for contact purposes only

Today's Date:

Email Required To Submit Form:

Electronic Authorization Signature

Checking this box you are consenting the above name is legit and authorized guardian, this is confirmation of e-signature.

Your message will be encrypted and can only be read by Kid Approved Pediatrics.