Patient Registration 18+

Pediatric Services, PA

Information:

Last Name:

First Name:

MI:

D.O.B.:

Sex:

Primary Language:

Race: select all that apply

Am. Indian or Alaskan

Asian

Black

Hawaiian

White

Unknown

Country where patient was born:

Decline to Answer

Mailing Address:

Street or PO Box:

Unit or apt #:

City:

State:

Zip:

Home Phone:

E-mail:

Who lives at this household?

(Please note, this information is being requested to improve intake of your child’s Social History.)

Emergency Contacts, other than parents: Name & Relationship

Add new row

How would you ideally prefer to we contact you regarding:

Medical Issues:

Home Phone Work Phone Cell Phone Home Email

Appointment Reminders:

Home Phone Cell Phone Home Email Work Email Text to Phone

Recall Notices:

Home Address Home Phone Work Phone Cell Phone Home Email

Billing Statements:

Home Address Home Email Work Email

General Practice Notices

Home Address Home Phone Cell Phone Home Email

Patient Portal Notifications:

Cell Phone Home Email Work Email

Additional Contact Questions:

Who should receive billing statements?

May all contacts have access to the patient’s records electronically?

Yes No

Referred by:

Insurance:

Primary Policy: Policy Holder’s Name:

Date of birth:

Policy Holder’s SSN:

Policy Holder’s Sex:

Male Female

Insurance Carrier:

ID#

Secondary Policy: Policy Holder’s Name:

Date of birth:

Policy Holder’s SSN:

Policy Holder’s Sex:

Male Female

Insurance Carrier:

ID#

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