Portal Patient Registration Continued

First Child's Full Name

First NameLast Name
Likes to be Called
Date Of Birth

MonthDayYear
Date
Second Child's Full Name

First NameLast Name
Likes to be Called
Date Of Birth

MonthDayYear
Date
Third Child's Full Name

First NameLast Name
Likes to be Called
Date Of Birth

MonthDayYear
Date
Fourth Child's Full Name

First NameLast Name
Likes to be Called
Date Of Birth

MonthDayYear
Date
PRIMARY CONTACT PERSON FOR FAMILY (this primary contact will be the preferred contact person for Reminder calls)
Check One (Mother):

Biological-MotherStep-MotherAdoptive-MotherFoster-MotherLegal GuardianOther
Check One (Father):

Biological-FatherStep-FatherAdoptive-FatherFoster-FatherLegal GuardianOther
Name
Birth Date

MonthDayYear
Date
Primary Phone
SSN
SECONDARY CONTACT PERSON FOR FAMILY
Check One (Mother):

Biological-MotherStep-MotherAdoptive-MotherFoster-MotherLegal GuardianOther
Check One (Father):

Biological-FatherStep-FatherAdoptive-FatherFoster-FatherLegal GuardianOther
Name
Birth Date

MonthDayYear
Date
Primary Phone
SSN
Who has primary physical custody? (if applicable)
In order to obtain more accurate Family Medical History requirements, if contacts listed above are NOT the BIOLOGICAL PARENTS, we now necessitate BOTH BIOLOGICAL PARENTS (if known) to be listed (fill in any and all information if known):
Biological Mother
Birth Date

MonthDayYear
Date
Biological Father
Birth Date

MonthDayYear
Date
If either biological parent listed above has NO parental rights per a SIGNED COURT ORDER a copy of that COURT ORDER is required to be on file.
EMERGENCY CONTACT/ CONSENT to TREAT (other than either the parent(s) or contact(s) listed above)
Name
Relationship to Patient
Phone
Authorize Treatment?

YesNo
Name
Relationship to Patient
Phone
Authorize Treatment?

YesNo
Name
Relationship to Patient
Phone
Authorize Treatment?

YesNo
Restrictions: Please do NOT discuss Medical history/status or financial history/status with the following people:
I understand if there are Custody Orders in place I must present current court order copies for my child’s file. If custody issues interfere with our physicians providing proper medical care you may be asked to find a facility that better suits your needs.
Privacy Constraints (Check One):

No restrictions. Okay to leave message / send mail.Restrictions - Person to person with patient / guardian onlyOther
When do you prefer your well visits?

MorningAfternoon
How did you hear about Etowah Pediatrics?

Already UseFriend RecommendationOnlineRadioFacebookOther
SIGNATURE

Clear
Relationship to patient
Date

MonthDayYear
Date
PRINT NAME
Should be Empty: