979-345-6522
Social Security Number
Birth Date
Age Home Address
City
State
Zip
Primary Phone Number
Untitled
homecell
E-mail Address School
Grade List any sports or extracurricular activities
Name
Driver License Number Address (if different than child's)
Phone Number
Phone Type
Secondary Phone Number
Employer's Name
Occupation
Driver's License Number
Address (if different than child's)
Yes NoIf yes, Doctor's name?
When was your child's last doctor visit?
Yes No
What kind?
How often?
Reason
When?
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status. I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims and to any Physician or Health Care Provider to whom my child might be referred for medical reasons. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child.
Patient Signature and/or Responsible Party
Date