New Patient Registration
Please fill in the form below
Parent/Guardian # 1 Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Guardian # 2 Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Primary Email
*
Other Email
example@example.com
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
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The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
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Burundi
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Cameroon
Canada
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Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
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Cook Islands
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Dominican Republic
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Ethiopia
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Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
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Gibraltar
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Guam
Guatemala
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Guinea
Guinea-Bissau
Guyana
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Hong Kong
Hungary
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India
Indonesia
Iran
Iraq
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Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
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South Korea
Kosovo
Kuwait
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Laos
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Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
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Sri Lanka
Sudan
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
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Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
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Vatican City
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Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Primary Cell Number:
*
-
Name
Phone Number
Secondary Cell Number:
-
Name
Phone Number
Home Number:
-
Phone Number
Your Child/Children's names,Date of Birth, M/F.
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
Prefer not to answer
White
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Prefer not to answer
Language preference
Were your children ever patients here before?
Yes
No
If you are expecting, which hospital do you plan to deliver at?
What is your due date?
-
Month
-
Day
Year
Date
Name of OB/GYN?
If you are a transfer, what practice are you transferring from?
What is the reason for leaving your current practice?
Are your children up-to-date with their immunizations
Yes
No
Name of Insurance Company
*
Name of Responsible Parent/Guardian
*
First Name
Last Name
Date of Birth of Responsible Parent/Guardian
*
-
Month
-
Day
Year
Date
Insurance ID#
*
Insurance provided through an employer?
Yes
No
Who may we thank for referring you to Bay Street Pediatrics?
Relationship to Patient
Signature
Today's Date
-
Month
-
Day
Year
Date
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