PATIENT REGISTRATION FORM

Please correct the errors described below.

LIST ALL CHILDREN:

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

PARENT (OR LEGAL GUARDIAN) INFORMATION

MOTHER'S INFORMATION:

MOTHER'S INFORMATION:

BILLING ADDRESS (IF DIFFERENT FROM ABOVE)

EMERGENCY CONTACT INFORMATION

LIST ALL CHILDREN:

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INSURANCE INFORMATION:

    Please upload a file
    (Social security number if TRICARE)

    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.

    By signing below, you are agreeing to and understand the above financial agreement and that you understand, as the parent 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.

    Your message will be encrypted.