Patient Registration

New Patient Registration

Use this form to register up to five patients living at the same address.
Household Structure
Do all the children in your family live in the same household, at the same address?*

YesNo
Use this one form to register up to five children living in the same household.
If you have a blended family with children in separate households with different addresses, parents/guardians, and/or different insurance plans, then you must complete this form for EACH HOUSEHOLD.
How many children are you registering on this form?*
Today*

MonthDayYear
Date

Patient 1
Patient Name*

First NameMiddle NameLast Name
Nickname
Preferred Language
Date of Birth*

MonthDayYear
Date
Social Security Number
Gender*

MaleFemale
Race*

AsianBlackWhiteOther
Ethnicity*

HispanicNon-HispanicUnknown
Patient Cell Phone Number
If the patient is 13 years or older
Patient Email Address
If the patient is 13 years or older

Patient 2
Patient Name*

First NameMiddle NameLast Name
Nickname
Preferred Language
Date of Birth*

MonthDayYear
Date
Social Security Number
Gender*

MaleFemale
Race*

AsianBlackWhiteOther
Ethnicity*

HispanicNon-HispanicUnknown
Patient Cell Phone Number
If the patient is 13 years or older
Patient Email Address
If the patient is 13 years or older

Patient 3
Patient Name*

First NameMiddle NameLast Name
Nickname
Preferred Language
Date of Birth*

MonthDayYear
Date
Social Security Number
Gender*

MaleFemale
Race*

AsianBlackWhiteOther
Ethnicity*

HispanicNon-HispanicUnknown
Patient Cell Phone Number
If the patient is 13 years or older
Patient Email Address
If the patient is 13 years or older

Patient 4
Patient Name*

First NameMiddle NameLast Name
Nickname
Preferred Language
Date of Birth*

MonthDayYear
Date
Social Security Number
Gender*

MaleFemale
Race*

AsianBlackWhiteOther
Ethnicity*

HispanicNon-HispanicUnknown
Patient Cell Phone Number
If the patient is 13 years or older
Patient Email Address
If the patient is 13 years or older

Patient 5
Patient Name*

First NameMiddle NameLast Name
Nickname
Preferred Language
Date of Birth*

MonthDayYear
Date
Social Security Number
Gender*

MaleFemale
Race*

AsianBlackWhiteOther
Ethnicity*

HispanicNon-HispanicUnknown
Patient Cell Phone Number
If the patient is 13 years or older
Patient Email Address
If the patient is 13 years or older

Patient Addresses
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is there a different mailing address?*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Contact

Parent or Guardian
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number
Relationship to Patient(s)*
Marital Status
Employer
Occupation
Primary Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email Address*
example@example.com
Same Physical Address as Patient?*
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Same Mailing Address as Patient?*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Contact

Parent or Guardian
Is there a Secondary Contact?*
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number
Relationship to Patient(s)*
Marital Status
Employer
Occupation
Primary Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email Address*
example@example.com
Same Physical Address as Patient?*
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Same Mailing Address as Patient?*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing Contact
Who is responsible for billing?*

PatientPrimary ContactSecondary ContactOther
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number
Relationship to Patient(s)*
Primary Phone*
Please enter a valid phone number.
Email Address*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legal Information
If parents are divorced or separated, who has custody?
Are there any legal restrictions preventing the noncustodial parent from consenting to medical treatment for the child, or from accessing information about the child’s medical care?*

NoYes
If so, please explain and provide a copy of any legal paperwork that supports this restriction.*
Emergency Contact

Not a parent
Name*

First NameLast Name
Relationship to Patient(s)*
Primary Phone*
Please enter a valid phone number.
Email Address
example@example.com

Insurance
Do you have medical insurance*
Company*
Policy ID*
Group ID*
Policy Holder Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number
Gender

MaleFemale
Employer
Front of Insurance Card*

Please upload an image of the front of your insurance card (jpg, jpeg, png, gif, pdf).
Cancelof
Back of Insurance Card*

Please upload an image of the back of your insurance card (jpg, jpeg, png, gif, pdf).
Cancelof
Do you have secondary insurance*
Company*
Policy ID*
Group ID*
Policy Holder Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number
Gender

MaleFemale
Employer
Front of Insurance Card*

Please upload an image of the front of your insurance card (jpg, jpeg, png, gif, pdf).
Cancelof
Back of Insurance Card*

Please upload an image of the back of your insurance card (jpg, jpeg, png, gif, pdf).
Cancelof
Driver's License/State ID
Front of Driver's License/State ID*

Please upload a picture of the front of your driver's license or state photo ID (jpg, jpeg, png, gif, pdf).
Cancelof
Preferred Pharmacy
Pharmacy Name*
Pharmacy City*
Pharmacy Phone
Please enter a valid phone number.
Authorization
I authorize payment of authorized Medicaid and/or commercial insurance benefits directly to Summer Pediatrics, LLC, for any services provided to me or my dependent by Summer Pediatrics’ providers. I also authorize Summer Pediatrics, LLC, to release any medical information required by my insurance carrier to determine payment for services rendered.

I understand that I am financially responsible for certain amounts not covered by my insurance, which may include annual deductibles, copayments, charges denied as not covered by Medicaid or my insurance carrier, and services deemed not medically necessary.

Furthermore, I acknowledge that if my account is referred for collection, I will be responsible for all fees incurred in the collection process.
Signature

Clear
Name*
Relationship*
Should be Empty:

New Patient Registration

Household Structure

Patient 1

Patient 2

Patient 3

Patient 4

Patient 5

Patient Addresses

Primary Contact

Secondary Contact

Billing Contact

Legal Information

Emergency Contact

Insurance

Driver's License/State ID

Preferred Pharmacy

Authorization