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*
MaleFemale
Date*

MonthDayYear
Date
Elementary SchoolMiddle SchoolHigh SchoolMagnet SchoolSpecial School
Elementary School
Middle School
High School
Magnet School
Special School
County*
Grade*
Teacher's Name*

Dental Insurance Information
YesNo
Medicad Recipient ID Number
12 Digit Number
YesNo
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
YesNo
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.

Clear
YesNo
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.

Clear
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