New Patient Forms

Acknowledgement of Receipt of Notice of Privacy Practices For Valley Pediatrics, P.C.

By signing this document, I acknowledge that I have received a copy of VALLEY PEDIATRICS' Notice of Privacy Practices.

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.

Parent/Guardian Name(Print)

Parent/Guardian Signature

Date

Patient Name (Print)

Patient Signature (if not minor)

Date

For VALLEY PEDIATRICS' Use Only

Date acknowledgement received

-OR-

Reason acknowledgement was not obtained and dates attempts made:

Patient Data

Patient Name

D.O.B.

Social Security #

Sex

Male Female

Phone

Address

Mother's Name

Occupation

D.O.B.

SS#

Mother's Home Phone#

Mother's Work Phone#

Mother Employer

Employer Phone #

Father's Name

Occupation

D.O.B.

SS#

Father's Home Phone#

Father's Work Phone#

Father's Employer

Employer Phone#

Responsible Party

Parent/Guardian

Sex

Male Female

Street Address

Marital Status

S M D W Other

City

State

Zip

Home Phone#

Work#

Social Security #

D.O.B.

Employer

Status

FT PT Self Retired

Street Address

City

State

Zip

Insurance

Primary

Insurance Carrier

Policy#

Group#

Subscriber Name

Relationship to Patient

Secondary

Insurance Carrier

Policy#

Group#

Subscriber Name

Relationship to Patient

Other

Insurance Carrier

Policy#

Group#

Subscriber Name

Relationship to Patient

Referred By: Physician

-OR- Patient - Hospital - Physician Directory - Family Member - Friend - Newspaper - Yellow Pages

I authorize any holder of medical or other information about me to release this information to my insurance company; its intermediaries or carriers, to my attorney, or another physician office.
I hereby authorize direct payment of medical and/or surgical benefits, to include major medical benefits to which I am entitled, Medicare, Private Insurance, and any other health plan to Abington Memorial Hospital, Holy Redeemer and/or Doylestown Hospital.
I also permit a copy of this authorization to be used in place of its original. This assignment will remain in effect until revoked by me in writing.
I understand that I am financially responsible for ALL services provided to my child(ren), including COPAYMENTS and BALANCES NOT-COVERED or REMAINING AFTER INSURANCE BENEFITS.
I authorize Valley Pediatrics, P.C. and Valley Pediatrics at Warrington to give my child(ren) reasonable and proper medical care by today's standards.

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.

Signed

Date

give Valley Pediatrics, P.C. permission to call this

Phone number

with any test results or reports and leave a message on a voicemail or answering machine if no one answers.

I will notify Valley Pediatrics, P.C. if there is a change in the above phone number.

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

Chart#

I give Valley Pediatrics, P.C. permission to release my medical information to my parents.

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

School/ Camp/ Sport Record

Add new row

Chart #

Parent's Name(s)

Address

City

State

Zip

Home #

Emergency #

Family History Information Sheet

Patient Name

Race

Date

D.O.B.

Home Phone

Emergency#

Address

City

State

Zip

Pregnancy Duration

Baby's Birth Wt.

Delivery Hospital

Maternal Health & Compilations of Pregnancy:

Surgical Procedures or Hospitalizations since patient's birth

Yes No

If Yes, please explain

Mother's Name

D.O.B.

SS#

Health Status

Occupation

Father's Name

D.O.B.

SS#

Health Status

Occupation

Siblings

Add new row

Patient Health History - Please include immediate family members

Select one - If YES, please explain

Alcohol Use

Yes No

If Yes, please explain

Allergies

Yes No

If Yes, please explain

Anemia

Yes No

If Yes, please explain

Asthma

Yes No

If Yes, please explain

Birth Defects

Yes No

If Yes, please explain

Blood Disorder

Yes No

If Yes, please explain

Cancer

Yes No

If Yes, please explain

Cardiac

Yes No

If Yes, please explain

Crib Death (SIDS)

Yes No

If Yes, please explain

Diabetes

Yes No

If Yes, please explain

Drug Use

Yes No

If Yes, please explain

Endocrine

Yes No

If Yes, please explain

Hearing Problems

Yes No

If Yes, please explain

GI Illness

Yes No

If Yes, please explain

H/A-Migraines

Yes No

If Yes, please explain

Hereditary Disease

Yes No

If Yes, please explain

High Blood Pressure

Yes No

If Yes, please explain

High Cholesterol

Yes No

If Yes, please explain

Kidney Disease

Yes No

If Yes, please explain

Mental Retardation

Yes No

If Yes, please explain

Neuromuscular Disorder

Yes No

If Yes, please explain

Respiratory Disorder

Yes No

If Yes, please explain

Seizures

Yes No

If Yes, please explain

STD's

Yes No

If Yes, please explain

Stroke

Yes No

If Yes, please explain

Sudden Death(less than 50yrs)

Yes No

If Yes, please explain

Tobacco Use

Yes No

If Yes, please explain

Thyroid

Yes No

If Yes, please explain

Tuberculosis

Yes No

If Yes, please explain

Vision Problems

Yes No

If Yes, please explain

Other

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