New Patient Registration Form

New Patient Registration Form

You will need a photo of your insurance card for each child (front and back) to complete form. Register for child 1 on this form first, then at the end, you can add other children with the same information. If you have a blended family, or children >18 yrs old, please fill out separate forms for each so we contact the right person/patient/families for each. Thank you!
Please take a moment to review our Vaccine, Financial, and Office policies and make sure that Roadrunner is the right fit for your family. Thanks for taking the time to learn about us - we look forward to learning about you!
PATIENT Details:
Yes, to confirm receipt.Yes, to confirm receipt and schedule an URGENT/SICK appointment.Yes, to confirm receipt and schedule an upcoming WELL VISIT/PHYSICAL.No, I already have an appointment made.No, I'll call you when we need you.
Patient's Full Name*

First NameLast Name
Date of birth:*

MonthDayYear
Date
Patient Gender:*
Primary Address*

Street Address

Street Address Line 2

CityState

Zip Code
PATIENT Phone Number*
if patient has a cell phone, please list their number. If not, please leave best contact number. Format: (000) 000-0000.
PATIENT'S E-mail*
If patient doesn't have an email, please enter responsible parent's email.
Does this PATIENT want updates on results, appointments, medical information from our office? *
If >18, this will be automated to YES in our office, regardless of your response. Call our office to change information workflow.
PCP: *
Does the PATIENT consent to HIPAA compliant messages sent to their cell phone?
From which office/PCP are you coming? Please enter office name, PCP name, and phone number.
Also note that you will need to sign your current office's release of medical records to get your chart sent to Roadrunner Pediatrics. Our fax is 520-457-5692.
HIPAA Policy

Vaccine Policy

Financial Policies

Office Policies
I have reviewed the Roadrunner Pediatrics Vaccine Policy, Financial Policies, and Office Policies. I have seen the HIPAA policy of RRP and have reviewed this via the links above. *

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Parent One's Full Name (Main Contact) *

First NameLast Name
Parent One's DOB*

MonthDayYear
Date
Relationship to Patient*
When was the date of your child's last well visit/annual physical exam? (month and year if exact date is unknown).
If Parent One is the insured, please enter SSN:
Is the Parent Address the same as the Patient?*
Parent One's Address:

Street Address

Street Address Line 2

CityState

Zip Code
Parent One's Cell Phone: *
Please enter a valid phone number.Format: (000) 000-0000.
Parent One's Email:*
example@example.com
To which modality would Parent One like information regarding their children's medical information (medical results, appointment reminders, general information)?*
If your child is >18yrs old, all information will go to them until you call our office to make other arrangements.
Would Parent One like Portal access for this patient?*
YesNo, my child is 18 or olderNo, I don't want text messages for any medical information
Parent Two's Full Name (if applicable)

First NameLast Name
Parent's Two's Address: (if same as patient AND Parent One, may leave blank)

Street Address

Street Address Line 2

CityState

Zip Code
If Parent Two is the insured, please enter SSN:
Parent Two's DOB

MonthDayYear
Date
Relationship to Patient
Parent Two's Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Parent Two's Email:
example@example.com
YesNo
To which modality would Parent Two like information regarding their children's medical information (medical results, appointment reminders, general information)?
If your child is >18yrs old, all information will go to them until you call our office to make other arrangements.
Would Parent Two like Portal access for this patient?
To which parent should the billing statements go? *
Which parent holds the insurance (the parent/guardian under which insurance is named): *
DOB of Insured Parent: *

MonthDayYear
Date
Insurance Company:*
Please list the name of your insurance company
Member Number on Insurance ID Card:*
Group Number on Insurance Card (if applies):
Please upload photo of insurance card FRONT:

Cancelof
Please upload photo of insurance card BACK:

Cancelof
If you have other children for which all the information is the same, please add their information below. If they are step-children who have different primary addresses, children with different insurances, or children > 18yrs of age, please fill out a separate form and click submit below. Thank you!
Sibling:

First NameLast Name
Date of birth:

MonthDayYear
Date
Patient Gender:
When was the date of your child's last well visit/annual physical exam? (month and year if exact date is unknown).
Patient Phone Number
if patient has a cell phone, please list their number. If not, you can leave this blank.Format: (000) 000-0000.
Patient's E-mail
If patient doesn't have an email, please leave blank.
Does this patient want updates on results, appointments, medical information from our office?
If >18, this will be automated to YES in our office, regardless of your response. Call our office to change information workflow.
PCP:
Please upload photo of insurance card FRONT (if different from siblings):

Cancelof
Please upload photo of insurance card BACK (if different from siblings):

Cancelof
Sibling:

First NameLast Name
Date of birth:

MonthDayYear
Date
Patient Gender:
When was the date of your child's last well visit/annual physical exam? (month and year if exact date is unknown).
Patient Phone Number
if patient has a cell phone, please leave blank. Format: (000) 000-0000.
Patient's E-mail
If patient doesn't have an email, please leave blank.
Does this patient want updates on results, appointments, medical information from our office?
If >18, this will be automated to YES in our office, regardless of your response. Call our office to change information workflow.
PCP:
Please upload photo of insurance card FRONT (if different from siblings):

Cancelof
Please upload photo of insurance card BACK (if different from siblings):

Cancelof
Sibling:

First NameLast Name
Date of birth:

MonthDayYear
Date
Patient Gender:
When was the date of your child's last well visit/annual physical exam? (month and year if exact date is unknown).
Patient Phone Number
if patient has a cell phone, please leave blank.Format: (000) 000-0000.
Patient's E-mail
If patient doesn't have an email, please leave blank.
Does this patient want updates on results, appointments, medical information from our office?
If >18, this will be automated to YES in our office, regardless of your response. Call our office to change information workflow.
PCP:
Any comments or requests as you register with Roadrunner Pediatrics?
Signature of Responsible Guardian: *

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Name of Signing Guardian:*

First NameLast Name
Please upload photo of insurance card FRONT (if different from siblings):

Cancelof
Please upload photo of insurance card FRONT (if different from siblings):

Cancelof
When was the date of your child's last well visit/annual physical exam? (month and year if exact date is unknown).
Should be Empty: