• All About Kids Pediatrics

  • Pediatric Patient Registration Form

    By completing this questionnaire you provide us with important, basic information for our records.

     

    ** PLEASE NOTE: If you are expecting a child that has NOT yet been born, please wait until AFTER birth to fill out this form

     

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    Welcome to Our Practice!

    Thank you for choosing our office for your child's care. To help make the registration process as smooth as possible, please review the information below.

    Medical Records Request

    Please complete the Medical Records Request at the end of this form. We are unable to schedule well-child appointments until we have received your child's previous medical records.

    Depending on your previous provider, medical records may take anywhere from a few days to several weeks to arrive. If you have not been notified by our office that your records have been received, please contact your previous provider to check on the status of your request.

    Scheduling Well Visits

    Dr. Mulato is the sole provider in our practice, and well-child appointments are usually booked out two to three months in advance. Appointment availability is reserved for newborns, who will be accommodated as needed.

    To help keep your child on schedule with recommended preventive care, we encourage you to book well-child visits as far in advance as possible. This is especially important for children under 2 years of age, as they require more frequent well visits.

    Next Step

    After completing this form, please complete New Patient Registration – Part 2. Once we have received both completed forms, we will add your child to our system.

     

  • Patient Info

  • Sex*

  • Parent/Legal Guardian Info

  • Sex*
  • Sex
  • Patient lives with*
  • Insurance Billing Statement Mailed To*

  • In case of an emergency, in which a parent/legal guardian cannot be reached, we may need to call someone on your child's behalf. Please list below the name of someone we have your permission to contact if necessary:

     

  • Format: (000) 000-0000.
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • CONSENT FOR CONTINUING TREATMENT OF MINOR CHILD

  • I, the parent/guardian of the minor child listed below, do hereby consent to any diagnosis or treatment rendered under the general or specific instructions of All About Kids Pediatrics.

  • Child's Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Today's Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Primary Insurance

  • Insurance Subscriber Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • TO CONFIRM THAT WE CAN ACCEPT YOUR INSURACE, 

    PLEASE UPLOAD A PICTURE OF THE FRONT AND BACK OF YOUR INSURANCE CARD

     

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  • Secondary Insurance

  • Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year

  • Financial Responsibility for Services Rendered by All About Kids Pediatrics

  • I acknowledge that acceptance of my insurance information is not a guarantee of payment by my health plan until the claim has been processed and paid. I further understand that if my claim is not accepted for payment I am personally responsible for payment of medical services rendered to myself or a member of my family.

     

    I acknowledge that medical billing statements for services rendered by All About Kids Pediatrics will be sent to the person who carries the insurance for the patient/family member.

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • ASSIGNMENT OF BENEFITS/RELEASE OF INFORMATION

  • I authorize and direct payment to All About Kids Pediatrics of any insurance benefits including hospital insurance and unemployment compensation disability benefits otherwise payable to or on my behalf for All About Kids Pediatrics, LLC including emergency services, at a rate not to exceed All About Kids Pediatrics, LLC actual charges. I understand that I am financially responsible for charges not paid pursuant to this agreement. I further agree that any credit balance resulting from payment of insurance or other sources may be applied to any other account owed to All About Kids Pediatrics, LLC by me. I also give permission to All About Kids Pediatrics, LLC to release medical information about my child when required by the insurance company or the government agencies responsible for the payment of my child's medical bills.

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Acknowledgement of Receipt of Notice of Privacy Practices

  • Your name and signature on this sheet indicate that you have been given access to a copy of the Notice of Privacy Practices on the date indicated. If you have any questions regarding the information in the Notice of Privacy Practices, please do not hesitate to contact our office. Also, a copy is posted on our website at www.aakpediatrics.com

     

  • Patient's Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Vaccine Policy Acknowledgement Form

    • All About Kids Pediatrics believes that immunizing our children and young adults is the single most important health-promoting intervention we perform as healthcare providers. 
    • There is overwhelming evidence that vaccines are safe, effective, and not associated with autism or any other neurodevelopmental conditions.
    • We endorse the recommended vaccine schedule as established by the Centers for Disease Control (CDC) and the American Academy of Pediatrics (AAP). There is no accepted alternative.
    • We are unable to accept/accomodate children whose parents refuse to vaccinate unless there is a true medical contraindication; it is our duty to keep our vulnerable at risk children safe from exposure to devastating vaccine-preventable diseases.
    • We are happy to address and answer all your questions and concerns regarding vaccinating your children and pledge to always provide the most up to date CDC Vaccine Information Sheet (VIS) and discuss possible side effects at each visit for vaccination.                                                                                                                           
    • Please refer to the following sources for further information.
      • American Academy of Pediatrics (www.aap.org/healthtopics/immunizations.cfm
      • Centers for Disease Control and Prevention (www.cdc.gov/vaccines)
      • Immunization Action Coalition (www.immunize.org)

    I acknowledge that I have read and understand All About Kids Pediatrics, LLC's Vaccine Policy.

  • Patient's Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Health History

  • Patient Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

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    Newborn History - if your child is currently under 3 years old at this time

     

     

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    Type of delivery

  • C-section

  • ***PLEASE BE SURE TO CHECK THE BOXES THAT SAY NO IF THAT SECTION DOES NOT PERTAIN TO YOUR CHILD AT THIS TIME AND MAKE SURE TO FILL OUT THE SECTIONS THAT DO. THESE ANSWERS ARE VERY IMPORTANT FOR THE DOCTOR SO THAT YOUR CHILD CAN RECEIVE THE APPROPRIATE CARE.***

  • Allergies

     

    If no allergies, please select "No Allergies"

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    Surgical History

     

    If no history of surgeries, please select "No Surgeries" 

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    Medical History

     

    If no history of diseases or conditions, please select "No Diseases or Conditions"

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    Family History

     If positive, please specify which family member and if alive or deceased.

     

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    Medications

     

    If no history of medications, please select "No Medications"

  • REQUEST FOR MEDICAL RECORDS

    IF YOU DO NOT HAVE ALL HISTORICAL MEDICAL RECORDS FOR YOUR CHILD(REN), PLEASE LIST PREVIOUS PROVIDER INFORMATION BELOW
  • Format: (000) 000-0000.
  • Patient's Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year

  • If you are requesting records for more than one child, list them below.

  • Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year

  • I, hereby authorize All About Kids Pediatrics, LLC to obtain copies of medical records from:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Reason for release of records:

  • Information to be Released:

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: