KAE Cubs Pediatrics-Patient Registration Form
Patient Information
Patient Full Name:
DOB:
-
Month
-
Day
Year
Date
Sex:
Male
Female
Race:
American Indian
Alaska Native
Asian
Black or African American
Native Hawaiian
White
Declined
Patient Cell phone (if has one)
Format: (000) 000-0000.
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Declined to Answer
Pharmacy name and Address:
Pharmacy Phone:
Format: (000) 000-0000.
Parent/Legal Guardian Information (Parent #1)
Full Name:
Relationship:
DOB:
-
Month
-
Day
Year
Date
Are the child's parents:
Married
Divorced
Other
Email:
example@example.com
Phone:
Format: (000) 000-0000.
Employer and Occupation:
Home Address:
City:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Legal Guardian Information (Parent #2)
Full Name:
Relationship:
DOB:
-
Month
-
Day
Year
Date
Email:
example@example.com
Phone:
Format: (000) 000-0000.
Employer and Occupation:
Home Address:
City:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact #1 (Parents or Others)
Name:
Relationship:
Phone:
Format: (000) 000-0000.
Emergency Contact #2 (Parents or Others)
Name:
Relationship:
Phone:
Format: (000) 000-0000.
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Patient Information
Child's Full Name:
Date of Birth:
-
Month
-
Day
Year
Date
Sex:
Male
Female
Birth History
lbs
oz
Length:
Gestational Age:
Delivery Type:
Vaginal
Cesarean
Was the pregnancy full-term
Yes
No
Complications during pregnancy or delivery?
Yes
No
If yes, explain:
Medical History
Has your child ever had the following? (Check all that apply)
Medical Conditions
Asthma
Seizures
Diabetes
Allergies (Food/Environmental/Drug)
Heart condition
Surgeries
Chronic ear infections
ADHD/ADD
Autism Spectrum
Frequent colds
Learning/Developmental delays
Other:
Allergies
None
Yes - list:
Allergies List
Current Medications:
None
Yes
Current Medications List
Family Medical History
Do any family members have a history of the following?
Asthma:
Parent
Sibling
Grandparent
Other
Diabetes:
Parent
Sibling
Grandparent
Other
High blood pressure:
Parent
Sibling
Grandparent
Other
Heart disease:
Parent
Sibling
Grandparent
Other
Seizures:
Parent
Sibling
Grandparent
Other
Autism/ADHD:
Parent
Sibling
Grandparent
Other
Mental health conditions:
Parent
Sibling
Grandparent
Other
Other conditions:
Social History
Who lives at home with the child?
Child attends:
Daycare
School
Home
Other:
Exposure to tobacco smoke?
No
Yes
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Immunizations
Are your child's immunizations up to date?
Yes
No
Not Sure
Immunization records provided?
Yes
No
Parent/Guardian Acknowledgment
I certify that the information provided above is complete and accurate to the best of my knowledge.
Name of Parent/Guardian (Printed):
Signature:
Date:
-
Month
-
Day
Year
Date
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KAE Cubs Pediatrics
Address: 1535 W. Merced Avenue, Suite 306, West Covina, CA 91790
Phone: 626-960-2977
Fax: 626-960-2979
HIPAA Privacy Notice Acknowledgment Form
Patient Name:
Date of Birth:
-
Month
-
Day
Year
Date
Acknowledgment of Receipt of Privacy Practices
I acknowledge that I have received, reviewed, and been given the opportunity to ask questions about the Notice of Privacy Practices from KAE Cubs Pediatrics. This notice describes how medical information about my child may be used and disclosed and how I can access this information.
I understand that a copy of the Notice of Privacy Practices is available to me upon request and is also available in the office and/or on the practice's website.
Parent/Guardian Name (Print):
Relationship to Patient:
Signature:
Date:
-
Month
-
Day
Year
Date
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KAE Cubs Pediatrics
1535 W. Merced Avenue, Suite 306, West Covina, CA 91790
Phone: (626) 960-2977 Fax: (626) 960-2979
Consent to Treat Form
I, the undersigned parent or legal guardian, hereby authorize KAE Cubs Pediatrics and its medical staff to provide medical care and treatment for my child listed below.
This consent includes, but is not limited to:
- Physical examinations
- Diagnostic procedures (e.g., laboratory tests, imaging)
- Administration of medications or vaccines
- Minor procedures as deemed necessary by the physician
- Emergency treatment if I cannot be reached in a timely manner
I understand that this consent remains valid until revoked in writing by me. I further acknowledge that I am legally authorized to consent to medical care for this minor.
Child's Full Name:
Date of Birth:
-
Month
-
Day
Year
Date
Authorization & Signature
Name of Parent/Guardian (Printed):
I certify that I am the parent or legal guardian of the above-named child and have the authority to authorize medical care. I have read and understood this consent form.
Signature of Parent/Guardian:
Date:
-
Month
-
Day
Year
Date
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Primary Insurance Name
Subscriber Name
Insurance Number or Member ID
Group Number
Subscriber Date of Birth
Upload front and back side of insurance card
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