New Patient Form

Patient Information

Child’s Name

Date of Birth

Social Security #

Gender

Male Female

Mother’s Name

Father’s Name

Home Address

City

State

Zip

Mailing Address

City

State

Zip

Home Phone

Contact email address

Mother’s Cell Phone

Father’s Cell Phone

Mother’s Employer

Father’s Employer

How did you hear about us?

Website

Facebook

Twitter

Seminar

Name

Patient’s Insurance Information

PRIMARY Insurance Name

Policy #

Subscriber Name

Date of Birth

Relationship to Patient

Parent Self Other

If other, please specify.

Pharmacy Information

Name

Phone

Fax

Address

Emergency Contact Information

Name

Relationship

Home Phone

Alternate Phone

Assignment of Benefits- Financial Agreement

I authorize and request my insurance company to pay benefits otherwise payable to me directly to Personalized Pediatrics; I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on behalf of myself or my dependent.

Patient’s Signature

(Parent’s signature if patient is under 18)

Date

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