New Patient Registration Form

Child's Name *

First Name Middle Name Last Name

Sex *

Date of Birth *

Month Day Year

Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Language(s) Spoken? *

Are there siblings?

Yes No

Mother's Name

First Name Last Name

Mother's E-mail

Mother's Phone

Area Code Phone Number

Father's Name

First Name Last Name

Father's E-mail

Father's Phone

Area Code Phone Number

Pediatrician *

First Name Last Name

Practice Name

Pediatrician's Phone *

Area Code Phone Number

Pediatrician's Fax Number

Area Code Phone Number

Does your child receive ongoing care from a specialist?

Yes No

Taking any medications, currently?

Yes No

If yes, please list it here

INSURANCE

Name of Insurance *

Aetna Blue Cross Blue Shield (BCBS) Medicaid TriCare Other

Carrier Name

Insured Name

Insured DOB

Member ID

Carrier Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Carrier Phone

Area Code Phone Number

Policy #

Group #

AGREEMENT

*As a courtesy to our clients, we will provide you with an explanation of benefits (EOB) from the above stated insurance and will submit your FULLY PAID invoice. If your insurance company denies coverage, we will submit of to TWO (2) invoices only. We will be happy to provide any information your insurance company requests such as clinical notes, evaluation and letters of necessity for a $25 fee (payable for submission). After 2 denials, it is your responsibility to work with your insurance company to gain coverage for services. There will be an additional *$25 fee for returned checks.

Signature *

Date *

Month Day Year Date Picker Icon

Submission of this form will stand in place for your signature. Submission of this form states that you agree to all terms and conditions outlined herein. *

Option 1 Option 2 Option 3

Child Case History