Patient Information Sheet

PATIENT INFORMATION

DATE:__________________________

Thank you for choosing our office. In order to serve you properly, we need the following information. Please PRINT and fill out this form completely. Last Name_________________________________Mothers Name________________________Fathers Name______________________ Address:____________________________________________________________________________________________________ City:_______________________________________ State: ________________________________ Zip:______________________ Home Phone Number: ________________________________________ Cell Number_____________________________________ E-mail Address:__________________________________________________ Referred by: _____________________________________________________ CHILDRENS NAMES: 1.___________________________________________

DOB ________________________________

2.___________________________________________

DOB_________________________________

3.___________________________________________

DOB_________________________________

4.___________________________________________

DOB_________________________________

FATHER:

DOB_____________________

Name_______________________________________________________ SSN______________________________ Occupation:____________________________________________________________________________________ Employed by:______________________________________________________________________________ Address:__________________________________________________________________________________ City:_________________________________________ State:____________________ Zip_______________ Work Number__________________________________

MOTHER:

Cell Number _______________________________

DOB____________________

Name_______________________________________________________ SSN________________________________ Occupation:___________________________________________________________________________________ Employed by:________________________________________________________________________________ Address:____________________________________________________________________________________ City:_________________________________________ State:____________________ Zip_________________ Work Number__________________________________

Cell Number _________________________________

OTHER PHONE NUMBERS Day Care_________________________________________ Phone Number________________________________ Pharmacy_________________________________________ Phone Number________________________________

INSURANCE INFORMATION Name of Insured:_____________________________________________________ Insurance Company Name :_____________________________________________________________________________________ Insurance Company Address:____________________________________________________________________________________ City:__________________________________________ State:____________________________ Zip:________________________ Union or Local # ________________________________ ID#_____________________________ Group#_____________________ How Much is Your Deductible?__________________________ How much is your Co-pay?_________________________________

Do you have additional insurance? If yes, please complete the following

YES _________________

NO _____________________

Name of Insured:_____________________________________________________ Insurance Company Name :____________________________________________________________________________________ Insurance Company Address:____________________________________________________________________________________ ID#_____________________________ How much is your Co-pay?_________________________________

ELIGIBILITY WAIVER: During the first 3 years of life, we see infants for routine well childcare at: 1 month of age, 2 months of age, 3 months of age, 4 months of age, 5 months of age, 6 months of age, 7 months of age, 9 months of age, 12 months of age, 15 months of age, 18 months of age, 2 Years of age, 2 ½ years of age, 3 years of age, and annually thereafter. Please verify that your insurance company provides full coverage for these visits prior to the visit. If it is determined that I am not eligible for coverage, I understand that I will be responsible for payment of all services provided. Signature (Parent or Legal Guardian)________________________________________________________Date:_________________