Age 4 to 17
Patient Registration Form
Patient Information
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
Sex at Birth
*
Please Select
Male
Female
Date of Birth
 -
Month
 -
Day
Year
Date
SSN
Contact Information
Home Number
Please enter a valid phone number.
Cell Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Email
*
example@example.com
Contact Preference: Ok to leave confidential messages
*
Home
Cell
Don't leave confidential messages
MCMC occasionally uses text messages or email for appointment reminders and other general information. I consent to be contacted via
Text
Email
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Number
*
Please enter a valid phone number.
Relationship to Patient
*
Income Information
Total household income last month
Total persons living in household last month
Decline to provide household income
*
Please Select
Yes
No
MCMC offers a sliding fee discount program. Would you like more information about the assistance program:
*
Yes
No
General Information
Marital Status
*
Single
Married
Widowed
Divorced
Student Status
*
Full Time
Part Time
Not a Student
Language Spoken
*
Interpreter Needed
*
Yes
No
Housing Status
*
Public Housing
Not in Public Housing
Homeless Status
*
Not Homeless
Doubling up
Shelter
Street
Transitional
Other
Migrant/Seasonal Status
*
Not a Migrant or Seasonal Farm Worker
Migrant (within last 24 months had to establish temporary home for purpose of employment in agriculture)
Seasonal (seasonal agricultural worker and has not had to establish temporary home for this employment)
Sexual Orientation
*
Straight (not gay or lesbian)
Lesbian or Gay
Bisexual
Don't Know
Chose not to disclose
Other
Gender Identity
*
Male
Female
Chose not to disclose
Transgender Female to Male
Transgender Male to Female
Other
Race
*
White
Black African-American
More than one race
Other Pacific Islander
American Indian
Asian
Native Hawaiian
Other
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Veteran Status
*
YES - I am a Veteran
NO - I am not a Veteran
Do you have a LIVING WILL?
*
Yes
No
Responsible Party Information
Relationship to Patient
Self
Spouse
Parent
Other
Name
*
First Name
Middle Name
Last Name
SSN
*
Date of Birth
*
 -
Month
 -
Day
Year
Date
Home Number
Please enter a valid phone number.
Cell Number
*
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
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Name
*
First Name
Last Name
Date of Birth
*
Insurance Information (Please give your insurance card to the receptionist)
Health insurance policies may cover a portion of the fees and MCMC staff will assist you in making claims. It is expected that you will inform us of changes in your family status or health insurance coverage. Please fill in the name of your insurance company(s), and sign below. By signing below, I authorize Morgan County Medical Center to assist me in obtaining third party benefits, to file benefit claims on my behalf, and to release any information necessary for the processing of my claim(s) to any of the insurance companies or third-party benefit agents listed below. I understand that such information may include diagnosis, dates of service, types of treatment, results of evaluations/assessments, actual progress notes, and other information about services received. This release shall remain in effect until all claims filed on my behalf have been processed.I authorize and request direct payment of my health insurance benefits to Morgan County Medical Center. This authorization shall apply to all covered health services that I receive at the Center. If requested, I have been provided with a copy of the fee scale.
Patient Name
First Name
Last Name
Signature
*
Today's Date
*
 -
Month
 -
Day
Year
Date
Primary Insurance
*
Check here if current card on file
No Insurance
Medicaid/TennCare
Medicare
Other (Employer/Private/Commercial)
Patient's Relationship to Insured
*
Self
Spouse
Child
Other
Plan Name
*
Member ID Number
*
Group Number
*
Effective Date (if known)
 -
Month
 -
Day
Year
Date
Insured Name
*
First Name
Last Name
Insured SSN
*
Insured Date of Birth
*
 -
Month
 -
Day
Year
Date
Secondary Insurance
Check here if current card on file
No Insurance
Medicaid/TennCare
Medicare
Other (Employer/Private/Commercial)
Patient's Relationship to Insured
Self
Spouse
Child
Other
Plan Name
Member ID Number
Group Number
Effective Date (if known)
 -
Month
 -
Day
Year
Date
Insured Name
Insured SSN
Insured Date of Birth
 -
Month
 -
Day
Year
Date
Consent for Evaluation and Treatment
Morgan County Medical Center (MCMC) is dedicated to providing comprehensive primary care and behavioral health services. Because wellness involves both the body and mind, our multidisciplinary team of providers work together to offer you high quality whole person healthcare. In order to provide you with comprehensive and coordinated care, your providers may involve other healthcare specialists as part of your care team. Members of your health care team will collaborate and share clinical information as needed to ensure enhanced continuity of care. Some services at MCMC may involve the use of telemedicine equipment. These services utilize high-speed electronic connections and incorporate healthcare industry-standard encryption and data security methods. While there is no guarantee these transmissions cannot be intercepted, great care is taken to prevent all unlawful access to electronic data. I understand, that if I am 16 years of age or older, I may consent for certain types of health services, including mental health services; if I am 18 years of age or older, I may consent for all other health services; otherwise my parent or legal guardian will need to consent to services. By signing this form, (parent or legal guardian signature, if required) I agree that I have read or had this form read and/or explained to me, that I understand it and that any questions I asked have been answered. I understand that I agree to be truthful in providing information. Thus, I hereby ask, agree, and consent to evaluation and treatment for myself and/or child(ren) as set forth above, including any studies or procedures that MCMC professional staff decide are necessary or appropriate. If signing as parent or guardian, I hereby represent and warrant that I am legally empowered and entitled to make such decisions.
Patient’s or Guardian’s Signature
*
Today's Date
*
 -
Month
 -
Day
Year
Date
Privacy Practices/Patient Rights and Responsibilities
I understand that a copy of MCMC’s Privacy Practices is available upon request.
Patient’s or Guardian’s Signature
*
I understand that a copy of MCMC’s Patient Rights and Responsibilities is available upon request.
Patient’s or Guardian’s Signature
*
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Name
*
First Name
Last Name
Date of Birth
*
HIPAA Authorization
Keeping our patient’s information private is important and by default we will only disclose information related to your medical information including labs and test results, diagnosis, and treatment to the patient or legal guardian. However, if you would like to add other contacts that you would like for Morgan County Medical Center (MCMC) to disclose this information please complete the fields below:
Contact Name
First Name
Last Name
Relationship to Patient (Spouse, Child, etc.):
Contact Number
Please enter a valid phone number.
Contact Name
First Name
Last Name
Relationship to Patient (Spouse, Child, etc.):
Contact Number
Please enter a valid phone number.
Contact Name
First Name
Last Name
Relationship to Patient (Spouse, Child, etc.):
Contact Number
Please enter a valid phone number.
The duration of this authorization is indefinite unless otherwise changed in writing. MCMC understands that requests for health information from persons not listed on this form will require your specific authorization prior to the disclosure of any health information.
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Pediatric/Adolescent Health History Questionnaire
All questions contained in this questionnaire are strictly confidential and will become part of your child’s medical record
Patient Name
*
First Name
Middle Name
Last Name
Sex at Birth
*
Please Select
Male
Female
Patient Date of Birth
*
 -
Month
 -
Day
Year
Date
Child's Preferred Name
Height
*
Weight
*
Hair Color
*
Eye Color
*
Mother's Name & Occupation
*
Father's Name & Occupation
*
Guardian's Name (if applicable)
Guardian's Relationship to Child
Parent's Relationship
*
Married
Not Married
Separated
Divorced
Other
Who is providing this information about the patient?
*
Who does the child live with most of the time?
*
Who else does the child stay with?
*
Who provides child care?
*
Mom
Sister/Brother
Babysitter
Daycare
Dad
Grandparent
Guardian
Other
How many days per week?
Name of Daycare?
Number of Brothers and Sisters (include ages)
List all who live in the household
*
Previous or referring Doctor
*
List other Doctors patient is seeing and their specialty
*
Immunization History
Are immunizations up to date?
*
Yes
No
Has the patient received immunizations elsewhere?
Yes
No
If yes, where?
Surgeries and Hospitalizations
Type of SURGERY and reason for SURGERY
Year
Hospital Name
Type of HOSPITALIZATION FOR ILLNESSES (include reason)
Year
Hospital Name
Type of PSYCHIATRIC ADMISSIONS and reason (include Substance Abuse Treatment)
Year
Hospital Name
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Name
*
First Name
Last Name
Date of Birth
*
Pediatric/Adolescent Family Health History
Patient is Adopted?
*
Please Select
Yes
No
If any family member has had health problem, please check the appropriate box:
Rows
Select Family Member
Select Family Member
Select Family Member
Attention Deficit Disorder
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Asthma
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Bipolar
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Hip Dysplasia
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Deafness
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Depression
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Development Delay
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Diabetes
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Eczema
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
High Cholesterol
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
High Blood Pressure
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Learning Disability
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Mental Retardation
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Migraines
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Over Weight
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Scoliosis
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Seizure Disorder
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Sickle Cell Disease
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Crossed Eye
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Heart Attack under age 55
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Cancer
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Select Family Member
Mother
Maternal Grandmother
Maternal Grandfather
Father
Paternal Grandmother
Paternal Grandfather
Sister
Brother
Other
N/A
Please list any other health issue and family member below
If the family member is deceased, list age and cause of death
Home Environment
Is patient exposed to smoke?
*
Yes
No
Type of home
*
Mobile Home
Apartment
Condominium
Duplex
House
Approximate age of home?
*
Water source in home
*
City
Well
Pets in home
*
Yes
No
List type of pets
*
Education
School Name
*
Current Grade in School
*
Describe current school performance
*
Special Education
*
Yes
No
Explain
Learning Disability
*
Yes
No
Explain
Resource Class
*
Yes
No
Special Needs
*
Yes
No
Repeating Grade
*
Yes
No
Gifted Program
*
Yes
No
Please list school's child has attended
Rows
School Name
Preschool/Daycare
Kindergarten
Elementary School
Middle School
High School
Other
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Name
*
First Name
Last Name
Date of Birth
*
Pediatric/Adolescent Family Health History
Medical Issues
Vision Problems
Hearing Problems
Seizures
GI issues, reflux
Allergies, Asthma, reactive airway disease
High Fevers
Head Injuries
Broken Bones
Stitches
Hospitalizations
Ear Infections
PE (ear) Tubes
Tonsils/Adenoids removed
Other Surgeries
Other medical issues
Please explain items checked above
Please list ALL medications patient is currently taking
(Include any medications swallowed, injected, inhaled or applied to the skin. Also list any vitamins or herbs that may be taken)
Current Medications
Rows
Medication Name
Dose
How often is the medication taken?
Medication One
Medication Two
Medication Three
Medication Four
Medication Five
Medication Six
Previous Medications (Other medications taken in the last 6 months not listed above including over-the-counter medications)
Rows
Medication Name
Dose
How often is the medication taken?
Medication One
Medication Two
Medication Three
Medication Four
Medication Five
Medication Six
Drug/Food Allergies
Rows
Name of Drug/Food Allergies
Type of reaction from
Drug/Food
Drug/Food Allergies
One
Drug/Food Allergies
Two
Drug/Food Allergies
Three
Drug/Food Allergies
Four
Drug/Food Allergies Five
Drug/Food Allergies
Six
Submit
Should be Empty: