New Patient Information Form

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OLD HARDING PEDIATRIC ASSOCIATES
PATIENT DATA FORM
Today’s Date ________________________
Patient’s Name________________________________________________________________________
□ Male or
□ Female
Date of Birth______________________________
Residence Phone________________________________________
Patient’s Address
____________________________________________________________
____________________________________________________________
Race (Choose one)
□ American Indian/Alaska Native
□ Asian
□ Black/African American
□ Native Hawaiian/Pacific Islander
□ White
□ Other Race
□ Unknown
□ Declined
Ethnicity (Choose one)
□ Hispanic or Latino
□ Non Hispanic or Latino
□ Declined to Report
Preferred Language (Choose one)
□ English
□ Spanish
□ French
□ Chinese
□ Other
Preferred Pharmacy: ___________________________________ Location: ______________________________________
Father’s Name ____________________________________________________________________
Date of Birth_________________________________ SS # ____________________________________
Home #_________________________ Work # ___________________________ Cell # ___________________________
Address (If different from child’s)
_____________________________________________________
_____________________________________________________
Mother’s Name ___________________________________________________________________
Date of Birth_________________________________ SS # ____________________________________
Home #_________________________ Work # ___________________________ Cell # ___________________________
Address (If different from child’s)
_____________________________________________________
_____________________________________________________
Email Address __________________________________________________________ (To receive OHPA correspondence)
*THIS SECTION IS FOR NEWBORNS ONLY:
Is patient being added to father’s insurance? Yes ________ No ________
If yes: Insurance Company: _________________________________Plan Name ____________________________________
Patient ID: _________________________________ Group Number: ________________________________________
_____________________________________________________
Is patient being added to mother’s insurance? Yes _________No ________
If yes: Insurance Company: _________________________________Plan Name _____________________________________
Patient ID: _________________________________ Group Number: ________________________________________
Have you applied for a TennCare plan for your child? Yes ________ No _________

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