Demographic Update printable pdf download

Demographic Update

Today’s Date: __________________________________Patient’s DOB: ___________________________________

Patient’s Full Name: _____________________________________________________________________________

Parent/Guardian Full Name: ______________________________________________________________________

Current Address: ________________________________________________________________________________

Home Phone: __________________ Work Phone: ________________________ Cell Phone: __________________

Which number should we try first to contact you? ____________________________________________________

Name of Current Insurance Company: ______________________________________________________________

Emergency Contact(s):

Please list name, phone number, and relationship (i.e. Grandmother, Neighbor, etc.)

•

1. _______________________________________________________________________________________

2. _______________________________________________________________________________________

3. _______________________________________________________________________________________

Please Circle which of your emergency contacts are authorized to bring your child in for evaluation and

treatment (labs, vaccines, procedures)? #1

Are there additional people who are authorized to bring your child in for evaluation and treatment (labs,

vaccines, procedures)? Y/N

If yes, please list full name, phone number, and relationship below:

1. ___________________________________________________________________________________________

2. ___________________________________________________________________________________________

3. ___________________________________________________________________________________________

If your child is between the ages of 16 years and 18 years, do you give permission for your child to be

evaluated and treated if he/she is not accompanied by a parent, legal guardian, or other authorized person?

Y/N

Printed Name of Person Completing Form: ___________________________________________________________

Signature of Person Completing Form: _______________________________________________________________

Demographic Update