PATIENT REGISTRATION FORM

TODAY'S DATE:

Patient’s name (last, first middle):

Nickname:

Sex:

Male Female

Date of Birth:

Preferred email AND Preferred Cell phone number (for appointment reminders and contacting)

Email:

Phone Number:

EMERGENCY CONTACT INFORMATION

Name of local friend or relative:

Relationship to patient:

Emergency contact #:

Alternate contact #:

INSURANCE INFORMATION:

Is this patient covered by insurance?

No, I will pay for visit Yes

If yes, please give us a copy of card

Add file

Please upload a file

1. PRIMARY INSURANCE:

HMSA

QUEST-HMSA

Tricare

Other:

If other, please specify:

Subscriber ID #:

(Social security number if TRICARE)

Coverage code:

Group:

Effective date

Subscriber name:

Patient’s relationship to subscriber

Self Child

Sex:

Male Female

Date of Birth

2. SECONDARY INSURANCE

HMSA

QUEST-HMSA

Tricare

Other:

If other, please specify:

Subscriber ID #:

(Social security number if TRICARE)

Coverage code:

Group:

Effective date

Subscriber name:

Patient’s relationship to subscriber

Self Child

Sex:

Male Female

Date of Birth

I certify that the above information is accurate and current to the best of my knowledge. By providing my cell phone number and/or email address, I consent to Reis Pediatrics contacting me regarding my child’s medical care via cell phone, text or email.

Credit Card Payment Authorization:

Visa Mastercard Prefer not to provide (Required for hospital newborns and visitors)

Name on Credit Card:

Card Number:

Exp. Date:

Security Code:

Billing Address:

By signing below, you are agreeing to and understand the above financial agreement and that you understand, as the patient and/or guarantor of the minor child described above as being the patient, that you are responsible for any charges incurred and agree to pay them as required within 30 days of receiving your billing statement.

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

Signature:

Date:

Your information will be encrypted.