PATIENT REGISTRATION

(Please complete all blanks)

Family Last Name:

Date:

Name of Child:

Birthdate:

Sex

M F

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Is anyone in the family American Indian or Alaskan Native:

Yes No

Parent Responsible for Payment:

Name:

Relationship:

Home Phone:

Address:

City:

State:

Zip:

Name

Employer:

Birthdate:

Work Phone:

Cell Phone:

Email address

Name

Employer:

Birthdate:

Work Phone:

Cell Phone:

Email address

Medical Insurance Information

None

Name of Company:

Policy Holder:

ID#:

Group #:

I authorize payment of medical benefits to my physician for professional services rendered.
I authorize the release of any medical information to my insurance company.

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:

Person to contact in case of an emergency other than parent

Name:

Phone:

If I am unavailable, I request The Pediatric Center, or any physician they may delegate, to give any and all medical or surgical care to the above named children. This includes my permission for the children to be admitted to a hospital and for the performance of surgery and anesthesia as deemed advisable by the above named physicians or their delegates.

Name:

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