Patient/child Information Template - Parental Authorization

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ABC PEDIATRICS, LTD.
Gus Rousonelos, MD 
Erin Shanks, MD
Karolyn Law, MD
Ushma Patel, MD
Pamela Persak, MD
CHILDREN’S INFORMATION
Last
First
Middle
Date of Birth
Sex (Circle)
____________________________________________________________
__________
M / F
____________________________________________________________
__________
M / F
____________________________________________________________
__________
M / F
____________________________________________________________
__________
M / F
____________________________________________________________
__________
M / F
____________________________________________________________
__________
M / F
CHILDREN’S ADDRESS
Street Address:
____________
_
___
__
__________
_
City, State, ZIP:
____________
Home (if different): (
)
Main Contact Phone: (
)
_
__________Mail statements to this address
PARENT’S INFORMATION
Mother’s Information
Father’s Information
Last
First
Date of Birth
Last
First
Date of Birth
_________
__________
_________
__________
Address (if different than above)
Address (if different than above)
Street Address:
______________
Street Address:
______________
City, State, ZIP:
________
City, State, ZIP:
________
Cell Phone (_______)___________________________________________
Cell Phone (_______)___________________________________________
E-mail address:
____________________________
E-mail address:
____________________________
Name of Employer:
________
Name of Employer:
________
Work Phone: (
)
________
Work Phone: (
)
________
Are you the primary insurance carrier?
Y
N
Are you the primary insurance carrier?
Y
N
__________Mail statements to this address?
__________Mail statements to this address?
EMERGENCY INFORMATION
Local Emergency Contact (other than parent):Phone: (
) ___________ ___________
Name:
_____________Relationship:
__
Address:
______________ _
AUTHORIZATION AND ACKNOWLEDGMENT
I authorize you to give my child/children reasonable and proper medical care by today’s standards. I hereby authorize the physician to release information
related to any claim. I recognize and accept full responsibility for all professional services rendered and further authorize the insurance company to pay
benefits directly to the physician.
Signature of Parent
Date
____
__
How were you referred to our practice?

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