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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__________________________________ Cell Number _______________________________

MOTHER: 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? YES _________________ NO _____________________


If yes, please complete the following

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:_________________