Patient Registration Form

Last Name

First Name

Middle Name

Birth Date

Gender

Male Female

Nickname

Address

Primary Phone

Secondary Phone

City

State

Zip Code

Status of Parent

Married Separated Divorced Widowed Unmarried

Female Parent(s) of Guardian(s) Information

Last Name

First Name

Primary Phone

Check One: Relationship to Patient

Mother Step-Mother Grandparent Foster Parent

Other

Email Address

Cell Phone

Address

Place of Employment

Social Security #

Date of Birth

Work Phone

Male Parent(s) of Guardian(s) Information

Last Name

First Name

Primary Phone

Radio buttons

Father Step-Father Grandparent Foster Parent

Other

Email Address

Cell Phone

Address

Place of Employment

Social Security #

Date of Birth

Work Phone

With whom does the child reside?

Father

Mother

Legal Guardian

Step Parent

Foster Parent

Other

Health Insurance

1) Company Name

2) Company Name

Policy ID #

Subscriber Name

Group Number

Check One: Relationship of Subscriber to Patient

Mother Father Grandparent Other

Check One: Relationship of Subscriber to Patient

Mother Father Grandparent Other

I authorize Pediatric Care North to release any and all medical records, pertaining to my child's health, to my insurance company for any requested additional information.

Parent's Signature

Date

By typing your name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Consent of Treatment

The physicians of Pediatric Care North have my permission to provide my child/children with any necessary treatment. The following persons have my permission to seek medical attention for my child/children in my absence.

1)

3)

2)

4)

Parent's Signature

Date

By typing your name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.