Patient Demographics

Primary Contact
Primary Contact Name*
Primary Contact Phone Number*
Please enter a valid phone number.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent 1
Parent 1 Name*
Relationship to Patient(s)*
Date of Birth*

MonthDayYear
Date
Social Security Number*
Does this parent live with the patient(s)?*

YesNo
Is this parent's physical address the same as the mailing address entered above?*

YesNo
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email Address*
example@example.com
Employer*
Occupation*
Parent 2
Parent 2 Name
Relationship to Patient(s)*
Date of Birth*

MonthDayYear
Date
Social Security Number*
Does this parent live with the patient(s)?*

YesNo
Is this parent's physical address the same as the mailing address entered above?*

YesNo
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email Address*
example@example.com
Employer*
Occupation*

Insurance
Are these patient(s) covered by medical insurance?*

YesNo
Primary Policy Holder's Name*
Social Security Number*
Date of Birth*

MonthDayYear
Date
Relationship to Patient(s)*
Insurance Carrier*
ID Number*
Group Number*
Emergency Contact

Someone who is not a parent
Emergency Contact Name*
Relationship to Patient(s)*
Phone Number*
Please enter a valid phone number.
Financial Guarantor

This is the person that will receive Billing Statements in the mail. Parents must agree on this and work arrangements out among themselves for payment issues. ABC Pediatrics will not become involved with domestic arguments over who receives Billing Statements.
Financial Guarantor*

Parent 1Parent 2Other
Financial Guarantor Name*
Relationship to Patient(s)*
Date of Birth*

MonthDayYear
Date
Social Security Number*
Does this person live with the patient(s)?*

YesNo
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email Address
example@example.com
Employer
Occupation
Referral

How did you hear about us?
We'd love to know who to thank for referring you to our office.

Agreements and Signature
I/we agree to:
- Give the doctors and staff permission to examine and treat my child.
- Authorize release of information to my insurance carrier for the purpose of processing claims. I hereby assign medical insurance benefits, to include major medical, to the doctors at ABC Pediatrics.
- Pay for services when rendered unless other arrangements are made prior to the visit.
- Should my account become delinquent, I agree to pay the necessary collection and/or attorney’s fees.
- Use of the after-hours triage service will be assessed a $20 fee if my insurance company does not pay in full.
- Be financially responsible for all charges deemed to be “non-covered benefits” by my insurance company even if the insurance’s Explanation of Benefits state the procedure is a “non-covered benefit” and “patient is not responsible.”
- Keep appointments in a timely manner. If not, I realize if I am 15 or more minutes late, my appointment may need to be rescheduled.
This assignment will remain in effect until revoked by me in writing.
Signature*

Clear
Printed Name*
Date*

MonthDayYear
Date
Should be Empty: