Patient Information Sheet

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PATIENT INFORMATION SHEET
DATE:_______________________
PATIENT NAMES:____________________________D.O.B.________________________
_____________________________________________D.O.B.________________________
_____________________________________________D.O.B.________________________
_____________________________________________D.O.B.________________________
PATIENT ADDRESS:________________________________________________________
____________________________________________________________________________
MOTHER’S NAME:__________________________ FATHER’S NAME:_____________________
ADDRESS:___________________________________ADDRESS:____________________________
_____________________________________________ ____________________________
PHONE (HOME)______________________________PHONE
(HOME)_______________________
PHONE (WORK)______________________________PHONE
(WORK)_______________________
CELL PHONE_________________________________CELL
PHONE_________________________
NAME OF
CAREGIVER/NANNY/GUARDIAN/BABYSITTER:_____________________________
NAME OF PRIMARY INSURANCE
HOLDER____________________________________________
INSURED DATE OF
BIRTH____________________________________________________________
EMPLOYER_______________________________________________________________________
SOCIAL SECURITY
NUMER___________________________________________________________
INSURANCE COMPANY
NAME________________________________________________________
PLEASE SUPPLY US WITH ANY OTHER ADDRESS OR TELEPHONE INFORMATION
THAT WILL HELP US TO CARE FOR YOUR CHILDREN. THANK YOU.
I AUTHORIZE THE CHILDREN’S MEDICAL GROUP TO RELEASE ANY MEDICAL
INFORMATION TO PROCESS INSURANCE CLAIMS AND AGREE TO PAY FOR ANY
NON-COVERED SERVICES ACCORDING TO THE TERMS OF MY INSURANCE POLICY.
IF I DO NOT PRESENT MY PROOF OF INSURANCE COVERAGE IN A TIMELY MANNER
(30 DAYS) I UNDERSTAND I WILL BE RESPONSIBLE FOR PAYMENT IN FULL
SIGNATURE______________________________________________________________________

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