2024 New Patient Registration

New Patient Registration

Bloom Pediatrics • 2055 E 14 Mile Road, Birmingham, MI 48009 • (248) 645-1740
Instructions

Complete this form once for each new patient. It contains the following sections:
1. Patient Demographics
2. Parents and Caregivers
3. Medical History

Parents and Caregivers
Parent 1 Name

First NameLast Name
Parent 1 Date of Birth

MonthDayYear
Date
Parent 1 Email Address
example@example.com
Parent 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent 1 Phone Type
Parent 2 Name

First NameLast Name
Parent 2 Date of Birth

MonthDayYear
Date
Parent 2 Email Address
example@example.com
Parent 2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent 2 Phone Type
Parents' Marital Status

Other
Patient's Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Bills Sent To

First NameLast Name
Billing Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
If one or both parents do not live in the home, who does the child live with? How often does the child see the other parent(s)?
Emergency Contact

First NameLast Name
Relationship to Patient
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Does anyone other than parents provide care for your child? For example, a relative, nanny, or friend. If so, list additional caretakers here:
Does the child attend daycare? If so, provide details.
Does the child attend school? If so, provide details.

Medical History
Is the patient under 12 months in age?
Describe any health issues for the mother or baby during pregnancy:
Describe any tobacco, drug, or alcohol use during pregnancy:
List any medications used during pregnancy:
Length of Pregnancy
Number of weeks
Birth
Birth Weight
Hopsital
Obstetrician
Describe any health issues the baby had at birth:
Does the patient have any major medical problems for which they are followed by a doctor or specialist?
Has the patient had any surgeries or hospitalizations?
Any emergency room visits over the past year? Concussions, broken bones, or asthma attacks, for example.
I attest that the information I have given on this form is correct and true to the best of my knowledge.
Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature
Date

MonthDayYear
Date
Should be Empty:

New Patient Registration