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New Patient Packet Form
DATE
*
DATE
PATIENTS NAME
*
First Name
Middle Name
Last Name
DOB
*
Age
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Sex
*
Male
Female
Preferred Language
Patient's SSN
*
Pharmacy
PCP Name
PCP Phone
PCP Fax
City of Practice
Patient Lives With
*
Mother
Father
Father's Name
First Name
Middle Name
Last Name
Father's DOB
Father's Address/Phone Same as Patient?
Yes
No
Father's Email
Home Phone
Address
City
State
Zip Code
Mobile Phone
Father's SSN
Father's Employer
Father's Occupation
Father's Employee Phone #
Mother's Name
First Name
Middle Name
Last Name
Mother's Address/Phone Same as Patient?
Yes
No
Mother's Email
Mother's Home Phone
Mother's Address
Mother's City
Mother's State
Mother's Zip Code
Mother's Mobile Phone
Mother's SSN
Mother's Employer
Mother's DOB
Mother's Occupation
Mother's Employee Phone #
Emergency Contact Name (other than the parents of patient)
Emergency Contact Phone
Primary Insurance
Name of Insurance Company
Insurance ID/Member #
Insurance Group #
Policy Holder's Name
Policy Holder's DOB
Secondary Insurance
Name of Insurance Company
Insurance ID/Member #
Insurance Group #
Policy Holder's Name
Policy Holder's DOB
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Medical History
Name
Relationship To Child
Birth Date
Health Problems
Name
Relationship To Child
Birth Date
Health Problems
Are there siblings not listed? If so, please list their names, ages, and where they live
What is the child''s living situation if not with both biological parents?
Lives With Adoptive Parents
Joint Custody
Single Custody
Lives with Foster Family
If one or both parents are not living in the home, how often does the child see the parent(s) not in the home?
Birth History
Birth Weight
Was the baby born at term
Yes
No
Or # of weeks?
Were there any prenatal or neonatal complications?
Yes
No
If there was any prenatal or neonatal complications please explain
Was a NICU stay required?
Yes
No
If there was any prenatal or neonatal complications please explain
During pregnancy, did mother
Use tobacco
Yes
No
Drink Alcohol
Yes
No
Use drugs of medications
Yes
No
Used prenatal vitamins
Yes
No
What drugs, medications or vitamins were used?
When were drugs, medications or vitamins used?
Was the delivery
Vaginal
Cesarean
If cesarean, why?
Was initial feeding
Formula
Breast Milk
How long breastfed?
Did your baby go home with mother from the hospital?
Yes
No
Explain why baby did not go home with mother from hospital
Do you consider your child to be in good health?
Yes
No
Don't Know
Explain why child may not be in good health
Does you child have any serious illnesses/medical conditions?
Yes
No
Don't Know
Explain why child may not be in good health
Has your child had any surgeries?
Yes
No
Don't Know
What surgeries?
Has your child ever been hospitalized?
Yes
No
Don't Know
Why was your child hospitalized?
Is your child allergic to medicines or drugs?
Yes
No
Don't Know
What medicines or drugs is your child allergic to?
Do you feel your family has enough to eat?
Yes
No
Don't Know
What medicines or drugs is your child allergic to?
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Financial Responsibility
Signature
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Date
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Month
-
Day
Year
Date
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Authorization to Treat
AUTHORIZATION TO RELEASE MEDICAL INFORMATION TOINDIVIDUALS/FAMILY MEMBERS
I do not authorize Little Steps Pediatrics, LLC to release any or allinformation concerning my medical care to any individual except as set forthabove.
No
I authorize Little Steps Pediatrics, LLC to release any or allinformation concerning my medical care to any individual except as set forthabove.
Yes
Name
First Name
Last Name
Relationship to Patient
Phone Number
Name
First Name
Last Name
Relationship to Patient
Phone Number
Name
First Name
Last Name
Relationship to Patient
Phone Number
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Notice of Privacy Practices
HIPAA Notice of Privacy Practices - THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION PLEASE REVIEW IT CAREFULLY
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Policies
Signature
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Vaccination Policy
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Care Availability Notice
Clinic/Care Availability Notice
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