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  • Patient Registration Form

  • Patient Name:      DOB:   Pick a Date   Gender:               
    Address:                  
    Phone #1:         Phone #2:         Phone #3:         
    Phone #1 belongs to:      Phone #2 belongs to:   
    Phone #3 belongs to:   

    Messages about lab work can be left on this phone #:         

  • Appointment reminder preferences
    Please choose ONE.

    Phone Call:         
    Text Message:         *Send a new text to 622622 with the message CPA to opt in.
    Email:      

  • Parent/ Guardian Information

  • Parent/Guardian Name:      DOB:   Pick a Date   Occupation:         Employer:      Email:      

  • Parent/Guardian Name:      DOB:   Pick a Date   Occupation:         Employer:      Email:      

  • Emergency Contact(s)

    These are trusted individuals outside of parents and legal guardians.

  • Emergency Contact Name:      Relationship to Patient:      
    Phone #:         Work/Home #:         

  • Emergency Contact Name:      Relationship to Patient:      
    Phone #:         Work/Home #:         

  • Insurance Information

    Fill out unless you gave a card TODAY

  • Primary Insurance Provider:      Effective Date:   Pick a Date   Claim Address:                  Phone#:         Member ID:        Group #:      Copay:      Policy Holder:      Relationship to Patient:      

  • Billing Information (if different than Parent/Guardian information)

    Name of Policy Holder:    Relationship to Patient: Address:            Phone #:         Home/Work #:         

  • Assignment of Insurance Benefits & Authorization to Release Information

    I hereby authorize payment of healthcare benefits to Clinical Pediatric Associates of North Texas for the services rendered by any person under the physician's supervision. I understand that I am financially responsible for any balance not covered by my insurance carrier. I also authorize Clinical Pediatric Associates of North Texas to release any medical information or incidental information that may be necessary for either medical care, processing applications for financial benefit and health care operations including my insured dependent(s) over 18 years of age.

  • Patient Name:      Parent/Guardian Name:    Parent/Guardian Signature:         Date Signed:   Pick a Date   

  • This information below is requested for statistical reasons only.

    Please Check one:

  • Should be Empty: