Sun Pediatrics

NEW PATIENT REGISTRATION FORM

PATIENT'S PERSONAL INFORMATION
Name: ________________________________________________ SSN: ________________________DOB: ______________________Sex: M or F
Address: ____________________________________________________________________________________________________________________

INSURANCE POLICY HOLDER (OR RESPONSIBLE PARTY IF UNINSURED) INFORMATION

Name: ____________________________________________Relationship to Patient: ______________________SSN: ________________________
DOB: ______________________ Drivers License No: ____________________________ State: _______________________________________
Address: ______________________________________________________________________________________________________________
Home Phone: _____________________________Cell Phone: ____________________________ E-Mail: ________________________________
Employer:______________________________________________________________________________________________________________
Employer Address:_____________________________________________________________________________________________________
Occupation: ___________________________ Work Phone: _______________________________O.K. to leave message at work? Y N
Primary Health Insurance Company: _____________________________________________________________________________________
ID/ Policy No: ______________________________Group Number: ____________________ Effective Date:___________________________
Secondary Health Insurance Company: __________________________________________________________________________________
ID/ Policy No: ______________________________Group Number: ____________________ Effective Date:___________________________

ADDITIONAL FAMILY INFORMATION

Other Parents Name: ___________________________________________ SSN: _______________________ DOB: ________________________
Employer: __________________________________________________________ Occupation: ______________________________________
Address: _____________________________________________________________________ Phone : __________________________________
IN CASE OF EMERGENCY
Emergency Contact: ___________________________________________________________________________________________________
Relationship to Patient: _______________________________Home Phone: ______________________Cell Phone: ____________________
PHARMACY INFORMATION
Address: _____________________________________________________________________ Phone : __________________________________
Authorization to Pay Benefits to Sun Pediatrics:
I hereby authorize Sun Pediatrics to release any medical information needed to process insurance claims and authorize payments directly to
Sun Pediatrics for all medical and surgical benefits. I agree that I am financially responsible on the day of service for any charges not
covered by this authorization or not covered by my insurance policy(s).

Parent or Guardian Signature: _________________________________________________Date: ___________________________________