Pediatric Ophthalmology and Strabismus: Patient registration

Pediatric Ophthalmology and Strabismus
PATIENT REGISTRATION
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Patient Name
Date of Birth

MonthDayYear
Date
Age
Sex

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family members also seen here:
Preferred contact phone number #
Parent/Guardian #1 Information
Name
Relationship to child:
Address, if different than child's

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Telephone

Area CodePhone Number
Date of Birth

MonthDayYear
Date
Employer
Occupation
Work Telephone

Area CodePhone Number
Cell Phone

Area CodePhone Number
E-Mail
example@example.com
Phone and Email Privacy Designation:

Parent/Guardian #1
Please note: Email is not a secure form of communication. Any issues which may be considered private or sensitive should not be discussed by email.
Parent/Guardian #1 cell phone:

OK to leave detailed messages regarding patient's careLeave messages with call back number only
Parent/Guardian #1 home phone:

OK to leave detailed messages regarding patient's careLeave messages with call back number only
Parent/Guardian #1 email:

OK to email detailed messages regarding patient's careEmail message with appointment reminders only
Parent/Guardian #2 Information
Name
Relationship to child:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Telephone

Area CodePhone Number
Date of Birth

MonthDayYear
Date
Employer
Occupation
Work Telephone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email
example@example.com
Phone and Email Privacy Designation:

Parent/Guardian #2
Please note: Email is not a secure form of communication. Any issues which may be considered private or sensitive should not be discussed by email.
Parent/Guardian #2 cell phone:

OK to leave detailed messages regarding patient's careLeave messages with call back number only
Parent/Guardian #2 home phone:

OK to leave detailed messages regarding patient's careLeave messages with call back number only
Parent/Guardian #2 email:

OK to email detailed messages regarding patient's careEmail message with appointment reminders only
Custody

Both parentsParent #1Parent #2Other
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES:
The Notice of Privacy Practices describes how this medical office may use and disclose your protected health information, and how you can get access to this information. I have received or have declined to receive a copy of the Notice of Privacy Practices (effective February 2014
Signature of Responsible Person

Clear
Relationship to Patient
Date

MonthDayYear
Date
Should be Empty:

Pediatric Ophthalmology and Strabismus

PATIENT REGISTRATION

Parent/Guardian #1 Information

Phone and Email Privacy Designation:

Parent/Guardian #2 Information

Phone and Email Privacy Designation:

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES: