New Patient Demographics

New Patient Demographics
First Child
Full Name

First NameMiddle NameLast Name
Likes to be called
Sex

MaleFemale
Birth Date

MonthDayYear
Date
Primary Language Spoken

EnglishSpanishOther
Ethnicity

Not HispanicHispanicUnknown
Race (Check all that apply)

Native AmericanAfrican AmericanAsianWhitePacific Islander
Second Child
Full Name

First NameMiddle NameLast Name
Likes to be called
Sex

MaleFemale
Birth Date

MonthDayYear
Date
Primary Language Spoken

EnglishSpanishOther
Ethnicity

Not HispanicHispanicUnknown
Race (Check all that apply)

Native AmericanAfrican AmericanAsianWhitePacific Islander
Third Child
Full Name

First NameMiddle NameLast Name
Likes to be called
Sex

MaleFemale
Birth Date

MonthDayYear
Date
Primary Language Spoken

EnglishSpanishOther
Ethnicity

Not HispanicHispanicUnknown
Race (Check all that apply)

Native AmericanAfrican AmericanAsianWhitePacific Islander
Fourth Child
Full Name

First NameMiddle NameLast Name
Likes to be called
Sex

MaleFemale
Birth Date

MonthDayYear
Date
Primary Language Spoken

EnglishSpanishOther
Ethnicity

Not HispanicHispanicUnknown
Race (Check all that apply)

Native AmericanAfrican AmericanAsianWhitePacific Islander
Primary Contact Person For Family

(this primary contact will be the preferred contact person for Reminder calls/ Financial Guarantor)
Check One:

Biological-MotherBiological-FatherStep-MotherStep-FatherAdoptive-MotherAdoptive-FatherFoster-MotherFoster-FatherLegal GuardianOther
Name
SSN
Birth Date

MonthDayYear
Date
Primary Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Employer
Do they live with the patient?

YesNo
Check preferred means of contact for messages:

CellHomeWorkEmail
Check preferred means of contact for Appt. Reminders:

CellHomeWorkEmail
Secondary Contact Person For Family
Check One:

Biological-MotherBiological-FatherStep-MotherStep-FatherAdoptive-MotherAdoptive-FatherFoster-MotherFoster-FatherLegal GuardianOther
Name
SSN
Birth Date

MonthDayYear
Date
Primary Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Employer
Do they live with the patient?

YesNo
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 Number
Please enter a valid phone number.
Authorize Treatment?

YesNo
Name
Relationship to Patient
Phone Number
Please enter a valid phone number.
Authorize Treatment?

YesNo
Name
Relationship to Patient
Phone Number
Please enter a valid phone number.
Authorize Treatment?

YesNo
Restrictions:
Please do NOT discuss Medical history/status or financial history/status with the following people:
Who Carries Primary Commercial Insurance:
Name
Birth Date

MonthDayYear
Date
Policy # / Group #
Name of Ins. Company:
Do you live with the patient?

YesNo
Relationship to Patient
Who Carries Secondary Commercial Insurance:
Name
Birth Date

MonthDayYear
Date
Policy # / Group #
Name of Ins. Company:
Do you live with the patient?

YesNo
Relationship to Patient
Check the box to accept

I understand if there are Custody Orders in place I must present current 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 only.Restrictions:
When do you prefer your well visits?

MorningAfternoon
How did you hear about Etowah Pediatrics?

Already UseFriend RecommendationOnlineRadioFacebookOther
Signature

Clear
Print Name
Relationship to Patient
Date

MonthDayYear
Date
Should be Empty:

New Patient Demographics

First Child

Second Child

Third Child

Fourth Child

Primary Contact Person For Family

Secondary Contact Person For Family

EMERGENCY CONTACT/ CONSENT to TREAT

Restrictions:

Who Carries Primary Commercial Insurance:

Who Carries Secondary Commercial Insurance: