Mobile Health Patient Registration Form

Mobile Health Patient Registration Form

Medical Associates Plus

Mobile Health Patient Registration Form
Child's Legal Name

First NameMiddle InitalLast Name
Date of Birth

MonthDayYear
Age
Gender
Date

MonthDayYear
Date
Please Select School Level
Elementary School
Middle School
High School
Magnet School
Special School
County
Grade
Teacher's Name

Dental Insurance Information
Does your child have dental Medicad/PeachState?
Medicad Recipient ID Number
12 Digit Number
Does your child have private dental insurance?
Primary Card Holder Name
Primary Card Holder DOB

MonthDayYear
Date
Primary Card Holder SSN#
Primary Card Holder Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Card Holder Phone Number

Area CodePhone Number
Employer
Dental Insurance Company
Insurance Company Phone Number

Area CodePhone Number
Member ID#
Group#

Consent for Treatment
Do you consent to Dental treatment?
I am the parent/legal guardian of the minor child listed above. I consent to my child receiving Dental treatment, and allow the school nurse and Dental provider to view Dental records. I give Medical Associates Plus permission to treat my child and I have seen HIPAA right documentation.
Do you consent to Medical treatment?
I am the parent/legal guardian of the minor child listed above. I consent to my child receiving Medical treatment, and allow the school nurse and Dental provider to view Medical records. I give Medical Associates Plus permission to treat my child and I have seen HIPAA right documentation.
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