Patient Registration Form

New Patient Registration

P: (615)-882-4900 F: (615)-622-8901
Date:

MonthDayYear
Date
Patient's Full Name:

First NameMiddle NameLast Name
Preferred Name or Nickname:
Date of Birth:

MonthDayYear
Date
Pronouns:
Birth Sex:
Race:
Preferred Language:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School/Grade:
Siblings (Names and DOBs):
Insurance Information

*Please bring your insurance card and form of payment for copays, if applicable, to every visit.
Does this patient have medical insurance?

YesNo (Self-Pay)
If your child has TennCare, is Dr. Breanna Lustre listed as your child's PCP (primary care provider)?

Yes- I have either called TennCare to switch the designated PCP to Dr. Breanna Lustre OR my child's insurance card already lists Dr. Breanna Lustre as PCP.No- I understand that I must call TennCare to change the designated PCP to Dr. Breanna Lustre before scheduling an appointment at East Nashville Pediatrics.
Name of Primary Insurance Company:
Subscriber's Name:
If insurance is through TennCare, please list patient name here.
Subscriber's Date of Birth:
If insurance is through TennCare, please list patient's DOB.
Patient's Relationship to the Subscriber:

Self (please select if insurance is TennCare)ChildOther
Policy Number:
Group Number:
Name of Secondary Insurance (if applicable):
Patient's Relationship to the Subscriber:

SelfChildOther
Policy Number:
Group Number:
Pharmacy Information:
Pharmacy Name:
Address:
Telephone Number:
Family/Contact Information
Please list parents/guardians (include relationship to child) that the patient primarily resides with:
Relationship Status of Parents/Guardians:

Single ParentPartnered/MarriedDivorced/SeparatedWidowedOther
Parent/Guardian #1 Name and DOB:
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
Occupation/Employer:
Parent/Guardian #2 Name and DOB:
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
Occupation/Employer:
The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize East Nashville Pediatrics PLLC or insurance company to release any information required to process my claims.I give permission for East Nashville Pediatrics to contact me via e-mail and/or text message.
Signature and date:

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New Patient Registration

Insurance Information

Pharmacy Information:

Family/Contact Information