New Patient Registration Form

New Patient Registration

Please fill in the form below
Parent/Guardian # 1 Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Parent/Guardian # 2 Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Primary Email*
Other Email
example@example.com
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Cell Number:*

Name Phone Number
Secondary Cell Number:

Name Phone Number
Home Number:

Phone Number
Your Child/Children's names, Date of Birth, M/F.
Race

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderPrefer not to answerWhite
Ethnicity

Hispanic or LatinoNot Hispanic or LatinoPrefer not to answer
Language preference
Were your children ever patients here before?

YesNo
If you are expecting, which hospital do you plan to deliver at?
What is your due date?

MonthDayYear
Date
If you are a transfer, what practice are you transferring from?
Practice number:
What is the reason for leaving your current practice?
Are your children up-to-date with their immunizations

YesNo
Name of Insurance Company*
Name of Responsible Parent/Guardian*

First NameLast Name
Date of Birth of Responsible Parent/Guardian*

MonthDayYear
Date
Insurance ID#*
Insurance group #*
Insurance provided through an employer?

YesNo
Who may we thank for referring you to Bay Street Pediatrics?
Relationship to Patient
Signature

Clear
Today's Date

MonthDayYear
Date
Should be Empty: