Registration Form

Registration Form
Patient's Information
Patient's Photo
Patients Name*

First NameMiddle NameLast Name
Date of birth*

MonthDayYear
Date
Age*
Gender*

MaleFemale
Preferred Language*
Interpreter Needed?

YesNo
Patient Race/Ethnicity *
Primary Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Relation
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Relation
Email Address *
example@example.com
Preferred Contact Method:

Primary PhoneCell PhoneText to CellEmail
Pharmacy of Choice
How did you hear about us?

FacebookWebsiteFamily/FriendReferring ProviderHealth Ins PlanOther
Insurance Information
Primary Insurance
Policy Holder Name
Gender

MaleFemale
Subscriber Birthdate

MonthDayYear
Date
Relationship to the patient
Name of Insurance
Subscriber ID
Plan Name
Group Name
Group Number
Copay
Please provide a copy of your card (Front)
Please provide a copy of your card (Back)
Secondary Insurance
Policy Holder Name
Gender

MaleFemale
Subscriber Birthdate

MonthDayYear
Date
Relationship to the patient
Name of Insurance
Subscriber ID
Plan Name
Group Name
Group Number
Copay
Please provide a copy of your card (Front)
Please provide a copy of your card (Back)
Hospitalizations, Surgeries or Serious Illness
Please list the Date, Illness/Surgery, Hospital & Physician
Parent Information
Mother's Information
Name
Date of Birth

MonthDayYear
Date
SS#
Preferred Language
Interpreter Needed?

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method:

Primary PhoneCell PhoneText to CellEmail
Employer
Business Phone
Please enter a valid phone number.Format: (000) 000-0000.
Father's Information
Name
Date of Birth

MonthDayYear
Date
SS#
Preferred Language
Interpreter Needed?

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method:

Primary PhoneCell PhoneText to CellEmail
Employer
Business Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact

This should be someone other than a parent.
Name
Relationship to Child
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Responsible Party
Person To Receive Bills:

FatherMotherOther
If other, please complete this section:
Name
Relationship to Child
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Nutrition
Breast Fed?

YesNo
Amount
Frequency
Formula?

YesNo
Amount
Frequency
Type
Take Vitamins?

YesNo
Taking Iron?

YesNo
Home Life
Housing

OwnRentTransition HousingHomelessStaying with Friends/Family
Please list all persons living in the same house as the child and their relationship to the child.
Family History

Check any illnesses that the child or members of the child’s family have had:

Rows	Child	Family
Frequent Ear Infections
Diabetes
Frequent Colds/Sore Throats
Kidney/Bladder Problems
Croup
Seizures/Convulsions
Mumps, Measles, Chicken Pox
Early Heart Disease
Wheezing/Asthma
High Cholesterol
Pneumonia
High Blood Pressure
Eye Problems
Lung Disease/Tuberculosis
Dental Problems
Sexually Transmitted Disease
Hearing Problems
Alcohol/Drug use
Hay Fever/Seasonal Allergies
Cancer
Emotional Disorders/Suicide Attempt
Eczema/Skin Problems
Anemia/Blood Problems

Other Illnesses:
Medications
Allergies: Please list all the child’s allergies, including any allergic reaction to drug:
Pregnancy and Birth

Please answer the following questions related to the mother’s pregnancy and child’s birth.
Delivery was

VaginalC-Section
Hospital of Birth
Weeks of Gestation at birth
Birth Weight
Length
Pregnancy History
Problems at during labor or delivery
Days in NICU
Reason
Did the mother use any cigarettes, alcohol, recreation drugs or medication during her pregnancy?

YesNo
Developmental and Behavioral Issues
Did the child sit along by 7 months?

YesNo
Did the child walk alone by 14 months?

YesNo
Did the child say 3 words by 15 months?

YesNo
Is the child doing well in school?

YesNo
Does the child get along with other children?

YesNo
Health and Safety
Are there guns in the child’s house?

YesNo
Does the child use a toothbrush daily?

YesNo
Date of last Dental Exam

MonthDayYear
Date

Does the child use a car seat or seatbelt all the time?

Rows	Yes	No
Are there smoke detectors in the home?
Is the hot water temperature less than 125°?
Do you or someone in the household know CPR?

Check any of the following which the child has:

Nightmares/Sleep ProblemsIrritable/Bad TemperToilet Training ProblemsDiscipline ProblemsBed WettingSpeech IssuesBreath HoldingThumb Sucking
Signature
I confirm that the information provided is accurate and completed to the best of my knowledge. I understand that it is my responsibility to inform the office of any changes in this patient’s information or medical status.
Parent/Legal Guardian Signature
Relation to Patient
Date

MonthDayYear
Date
Should be Empty:

Registration Form

Patient's Information

Insurance Information

Primary Insurance

Secondary Insurance

Hospitalizations, Surgeries or Serious Illness

Parent Information

Mother's Information

Father's Information

Emergency Contact

Responsible Party

Nutrition

Home Life

Family History

Medications

Pregnancy and Birth

Developmental and Behavioral Issues

Health and Safety

Signature