979-345-6522
Social Security Number:
Birth Date:
Age: Home Address:
City:
State:
Zip:
Primary Phone Number:
Untitled
home cell
E-mail Address: (Required)* 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 License Number:
Address (if different than child's):
Yes No If yes, Doctor's name?
When was your child's last doctor visit?
Yes No
What kind?
How often?
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. 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 understand that where appropriate, credit bureau reports may be obtained.
