PEDIATRIC REGISTRATION
WESTERN WAKE WELLNESS, PLLC
PATIENT INFORMATION
Today's Date:
*
-
Month
-
Day
Year
Legal Name:
*
First Name
Last Name
Nickname:
Date of birth:
*
-
Month
-
Day
Year
City of Birth:
*
Age:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Format: (000) 000-0000.
Language:
*
English
Other
Social Security Number:
Mother's Name:
First Name
Last Name
Mother's Cell Phone:
Format: (000) 000-0000.
Mother's Work Phone:
Format: (000) 000-0000.
Mother's Email Address
Fathers Name:
First Name
Last Name
Father's Cell Phone:
Format: (000) 000-0000.
Father's Work Phone:
Format: (000) 000-0000.
Father's Email Address:
Child lives with:
The best way to contact me is:
*
Phone
Email/patient portal
Postal mail
Sex at Birth:
*
Male
Female
Gender:
*
Male
Female
Nonbinary
Transman
Transwoman
Other
My pronouns are:
*
She/hers
He/his
They/their
Do you think of yourself as:
*
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
I prefer not to answer
Other
My ethnicity is:
*
Hispanic or Latino
Not Hispanic or Latino
I prefer not to answer
GUARANTOR INFORMATION
(Person responsible for the bill) Please use full legal name
Relationship to Patient:
*
Parent
Foster Parent
Self
Spouse
Child
Other
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth:
*
-
Month
-
Day
Year
Home Phone:
Format: (000) 000-0000.
Social Security Number:
Employer Name & Address:
PRIMARY HEALTH INSURANCE
Please bring card with you to every appointment
Insurance Company:
Policy Holder Name:
Relationship to Patient:
Member ID #
Group ID #
Effective Date:
-
Month
-
Day
Year
SECONDARY INSURANCE
Insurance Company:
Policy ID #
Member ID #
Group #
Effective Date:
-
Month
-
Day
Year
Which pharmacy do you prefer to use for prescriptions?
Name / Address
Who may we thank for referring you to our practice?
Submit
Should be Empty: