Family Registration Form printable pdf download

Pediatric Associates of Western CT

2016

Family Registration

Primary Care Provider (PCP) - __________________________________________________________

Child 1: Last Name: ____________________________ First Name: ___________________________ MI: _____

D.O.B.: _____/_____/_____ Sex: _______ Primary Language: __________________

Ethnicity: Hispanic / Non-Hispanic / Unknown Race: Asian / Black / Hawaiian / White

Mailing Address: ________________________________________________________________

(Street or PO Box)

(City)

(State & Zip)

Home Phone: ( ____ ) ______ - __________ Cell Phone: ( _____ ) _______ - _______________

Child 2: Last Name: ___________________________ First Name: ____________________________ MI: _____

D.O.B.: _____/_____/_____ Sex: _______ Primary Language: __________________

Ethnicity: Hispanic / Non-Hispanic / Unknown Race: Asian / Black / Hawaiian / White

Mailing Address & Home Phone same as Child 1 (Circle One)

Yes / No

Child 3: Last Name: __________________________ First Name: _____________________________ MI: _____

D.O.B.: _____/_____/_____ Sex: _______ Primary Language: __________________

Ethnicity: Hispanic / Non-Hispanic / Unknown

Race: Asian / Black / Hawaiian / White

Mailing Address & Home Phone same as Child 1 (Circle One)

Yes / No

Child 4: Last Name: __________________________ First Name: _____________________________ MI: _____

D.O.B.: _____/_____/_____ Sex: _______ Primary Language: __________________

Ethnicity: Hispanic / Non-Hispanic / Unknown

Race: Asian / Black / Hawaiian / White

Mailing Address & Home Phone same as Child 1 (Circle One)

Yes / No

Parent 1: Name: ___________________________________ Relation to Patient: ________________________________

Lives with patient? Yes / No Date of Birth: ____ / ____ / ____ Social Security #: ____ - ___ - _____

Work Phone: ( ____ ) ______ - ___________ Cell Phone: ( ____ ) ______ - ___________

Email: __________________________________ Necessary for patient portal (please write legibly)

Employer: _________________________________ Occupation: ________________________________

How would you ideally prefer to be contacted regarding (circle one):

Medical Issues: Home Phone / Work Phone / Cell Phone / Home Email

Appointment Reminders: Home Phone / Cell Phone / Home Email

Recall Notices: Home Address / Home Phone / Work Phone / Cell Phone / Home Email

Billing Statements: Home Address / Home email

General Practice Notices: Home Address / Home Phone / Cell Phone / Home Email

Patient Portal Notifications: Cell Phone / Home Email

Review additional information on reverse side

Family Registration Form