Child Registration Form printable pdf download

REGISTRATION FORM

MUST BE COMPLETED IN FULL USING A BLACK INK PEN

Patient information

Legal Name _________________________________________________________Date of Birth_____________ M/F_____

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Child lives with: Mother

Father

Court Appointed Guardian: _______________________

Mother / Court Appointed Guardian Information (Paperwork must be provided for legal Guardians)

Name _______________________________________________________________Date of Birth_______________________

Address__________________________________________ City _______________ State _____ Zip ____________

Primary Phone #____________________________ Secondary Phone ____________________________

E-MAIL: ____________________________________________ would you like to receive updates via E-mail? Yes / No

If parents are divorced or separated, Mother has a right to request records and coordinate care? Circle Yes/ No

If no please explain: ____________________________________________________________________

Father / Court Appointed Guardian Information (Paperwork must be provided for legal Guardians)

Name _______________________________________________________________Date of Birth_______________________

Address__________________________________________ City _______________ State _____ Zip ____________

Primary Phone #____________________________ Secondary Phone ____________________________

E-MAIL: ____________________________________________ would you like to receive updates via E-mail? Yes / No

If parents are divorced or separated, Father has a right to request records and coordinate care? Circle Yes/ No

If no please explain: ____________________________________________________________________

I authorize Melmed Center to contact me by telephone with medical information pertaining to my child’s care. If

I am unavailable, this authorization gives Melmed Center permission to leave this information either on my

answering machine or with a member of my household .

Authorized Care Givers (Other than biological parents/guardians)

The following people are authorized to discuss personal health information with the Melmed Center. They are also able to

coordinate care, schedule and attend appointments and may be contacted in case of an emergency

(Only parents and legal guardians can request and transfer records)

Name ________________________________________ Relationship _________Phone Number ___________

PLEASE NOTE IF DIVORCED: LEGAL CUSTODY DOCUMENTS MUST BE PROVIDED

DIVORCED/SEPARATED FAMILIES

We strive to, but cannot always act as a mediator between parents under contentious circumstances. We also strive to avoid being “side-barred” by

parents, lawyers or other professionals; and we hope that is respected. Both parents are always welcome, explicitly and implicitly, at all visits; indeed

that is preferred. Parents are responsible for ensuring that coordination of each of their own schedules allows for both to be present.

This of course

requires a degree of cooperation, that if absent, will preclude the most optimal evaluation. If communication challenges exist which preclude that, it is

unfortunate, especially for the child. Melmed Center will work with both parents. Therefore, it is required that you complete both parents information

above unless the court dictates otherwise.

Furthermore, payment must be arranged by the time of the visit. We accept payment in advance, but

require it from the accompanying adult at the time of the appointment.

I UNDERSTAND AND AGREE TO ALL OF THE ABOVE________________________________________ Date ___________

Signature of Parent/Legal Guardian

Please turn the page over and complete the other side →

Pediatric 10/14/2014