Patient Registration Form (Minor)

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OFFICE USE ONLY
PATIENT REGISTRATION FORM (MINOR)
MOUNT CARMEL
NG Account # __________
Medical Group
Name ____________________________________________________________________________ ❏ male ❏ female
Address __________________________________________________________________________ Apt# ___________
City __________________________________________ State __________________________ Zip _______________
Birth Date______________________________ Age ________ Social Security # __________-__________-__________
❏ yes
❏ no School Name ______________________________________________________________
Student:
❏ both parents
❏ mother
❏ father
❏ other ______________________________________
Child lives with:
Guardian’s Name __________________________________________________________________________________
Mother’s Name ____________________________________________________________________________________
(If Different) Address ________________________________________________________________________________
Home Phone _____________________________________ Work Phone ____________________________________
Birth Date______________________________ Age ________ Social Security # __________-__________-__________
❏ yes
❏ no Employer ________________________________________________________________
Employed:
Father’s Name ____________________________________________________________________________________
(If Different) Address ________________________________________________________________________________
Home Phone _____________________________________ Work Phone ____________________________________
Birth Date______________________________ Age ________ Social Security # __________-__________-__________
Employed: ❏ yes
❏ no Employer ________________________________________________________________
❏ yes
❏ no
May we leave messages at home with other residents
❏ yes*
❏ no
May we leave personal health information on your answering machine/voicemail
❏ yes**
❏ no
May we contact you via e-mail or cellular telephone
❏ yes**
❏ no
May we contact you via text message
*Appointment reminders will be left on voicemail.
**We cannot ensure the confidentiality of information shared by these means.
Who may we contact in case of Emergency? Name ____________________________________________________
Relationship __________________________________________ Phone #1 ______________ #2 _______________
Who may we talk to about your child's medical concerns?
Note: Unless we have legal documents on file restricting access to medical information, both parent's have the right
to access a child's medical record. However, we cannot give any info personal health information to anyone other than
a parent unless you list him or her by name.
Name ________________________________________ Relationship ______________________________________
INSURANCE INFORMATION
Note: We require that your card be presented at every visit ~ OR~ if card is not available you must verify eligibility, and
provide ID#, group #, mailing address & provider services #. If not, you will be responsible for the cost of the office visit.
Primary Insurance Company____________________________________________________ Co-payment $__________
Card Holder Name ______________________________________________________ Birth Date _________________
Address ____________________________________________Social Security # __________-__________-__________
❏ self
❏ mother
❏ father
❏ other
Relationship to card holder:
Secondary Insurance ____________________________________________________________________________
Card Holder Name ____________________________________________________ Birth Date _________________
Address __________________________________________Social Security # __________-__________-__________
❏ self
❏ mother
❏ father
❏ other
Relationship to Card Holder:
Card(s) Copied: Primary: ❏ yes
❏ no
Secondary: ❏ yes
❏ no
I understand that when I sign this document that I am confirming that all information completed by me is correct, I
authorize contact in the means identified above and that any falsification can lead to my dismissal from this practice.
Signature ___________________________________________________________ Today's Date __________________
HOW DID YOU HEAR ABOUT US?
❏ 411
❏ HealthCALL
❏ Newspaper
❏ Referring Physician_____________________
❏ Brochure
❏ Insurance Listing
❏ Radio
❏ Other _______________________________
❏ Drive-By Signage
❏ Phone Book
❏ Shopping Cart
❏ Family or Friends
❏ Postcard
❏ Website
Medical Group 102-10-12 (reorder PS)

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