Patient Registration Form

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2012
2009
PATIENT REGISTRATION
Date:
How did you hear about us?
Patient Name (First Middle Last):
Social Security Number:
Sex:  M  F
Relationship to Guarantor:
Date of Birth:
Home Address:
City:
State:
Zip Code:
Preferred Telephone: (
)
E-Mail Address:
Race:
Ethnicity:
Preferred Language:
Mode of contact:  Telephone  Email
Siblings
Name
Sex (M/F)
DOB (mm/dd/yy)
Social Security #
who visit
this office:
Marital Status of Parents:
Married
Divorced or Divorce Pending
Single (never married)
Mother’s Name:
Date of Birth:
SS #:
Contact E-Mail Address:
(You may receive periodic email newsletters)
Home Address ( Same as Child):
City:
State:
Zip Code:
Home Phone: (
)
Employer:
Cell Phone: (
)
Work Phone: (
)
Father’s Name:
Date of Birth:
SS #:
(You may receive periodic email newsletters)
Contact E-Mail Address:
Home Address ( Same as Child):
City:
State:
Zip Code:
Home Phone: (
)
Employer:
Cell Phone: (
)
Work Phone: (
)
Primary Insurance Name:
_____
Effective Date:
Full Name of Insured:
Date of Birth:
SS#:
Employer:
Policy Type:  HMO  PPO  PPC  Other:
ID Number:
Group Number:
Co-Pay Amount:
Preferred Pharmacy Name:
Location/Phone:
Previous Physician:
IN CASE OF EMERGENCY
Name:
Relationship:
Phone: (
)
Name:
Relationship:
Phone: (
)
Financial Policy, Assignment Information, and Release of Information
I authorize the release of any information acquired in the course of treatment necessary to complete and file medical claims to
my insurance company on my behalf. I hereby acknowledge financial responsibility for costs of services rendered for me or for
the person whose account I am acting as guarantor. I authorize (assign) any insurance to be paid directly to Pediatric
Wizards or its assignees. I am responsible for any non-covered services, supplies, co-payment or deductibles. I am responsible
for knowing how my plan works, and I request medical services at this office. This is acceptable and assignment will be in force
for all future services by practitioners from this office.
Patient/ Parent/ Guardian Signature
Date
Witness Signature
Date

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