Patient Registration Form

Patient Information

Account #:

Last Name:

First Name:

Initial:

Address:

City:

State:

Zip:

Employer:

Address:

City:

State:

Zip:

Gender:

Male Female

Date of Birth:

Age:

Social Security #:

Home Phone:

Work Phone:

Referring Doctor:

Address:

City:

State:

Zip:

Responsible Party

Account #:

Last Name:

First Name:

Initial:

Address:

City:

State:

Zip:

Employer:

Address:

City:

State:

Zip:

Patient Relation to Guardian:

Gender:

Marital Status:

Date of Birth:

Age:

Social Security #:

Home Phone:

Work Phone:

Insurance Information

Primary Insurance:

Address:

City:

State:

Zip:

Telephone:

Effective Dates:

Subsciber/Policy Owner:

Insured Policy ID:

Group #:

Date of Birth:

Patient Relation to Subscriber:

Copay Amount:

Second Insurance:

Address:

City:

State:

Zip:

Telephone:

Effective Dates:

Subscriber/Policy:

Insured Policy ID:

Group #:

Date of Birth:

Patient Relation to Subscriber:

Copay Amount:

Emergency Contact Information

Name:

Relation to Patient:

Home Phone:

Work Phone:

Mobile Phone or Pager:

Authorization to Release Information

I hereby authorize Tomball Healthcare for Pediatrics, P.A. to release any medical Information claims relating to the medical care rendered by Tomball Healthcare for Pediatrics, P.A..

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.

Name/Signature:

Date:

Assignment of Medical Benefits

I authorize payments of medical benefits to Tomball Healthcare for Pediatrics, P.A. for any medical care rendered to myself or to my dependents. I understand that I am responsible for any amount not covered by my insurance.

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.

Name/Signature:

Date:

Your information will be encrypted.