stephenschulmanpediatrics.com - Parent/Patient Information

Patient Registration
Parent / Guardian 1 Information
Relationship to patient:

FatherMotherOther
Name:

First NameMiddle NameLast Name
Sex:

MaleFemaleOther
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
Date of Birth:

MonthDayYear
Date
Cell Phone:
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Home Phone:
Please enter a valid phone number.
SS#:
Preferred Contact for Appointment Reminders

Text to cellCall to home
Parent / Guardian 2 Information
Relationship to patient:

FatherMotherOther
Name:

First NameMiddle NameLast Name
Sex:

MaleFemale
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
Date of Birth:

MonthDayYear
Date
Cell Phone:
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Home Phone:
Please enter a valid phone number.
Parents are:

MarriedSingleDivorced
Primary Insurance Information
Insurance Company Name:
Name of Insured:

Parent 1Parent 2
SS# of Insured:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SS# of Insured:
ID #:
Group #:
Secondary Insurance Information
Insurance Company Name:
Name of Insured:

Parent 1Parent 2
SS# of Insured:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SS# of Insured:
ID #:
Group #:
Emergency Contact Information
Contact Name:
Relationship to Patient:
Cell Phone:
Please enter a valid phone number.
Home Phone:
Please enter a valid phone number.
Comment
Patient and Sibling Information

	Name	Date of Birth	Sex: M\F
1
2
3
4
5

Name of Referring Physician:
Name of Referring Friend or Family:
Assignment of Benefits / Authorization / Notice of Collection Action

I understand I am responsible for knowing the benefits my insurance plan provides. In doing so, it is also my responsibility to verify proof of insurance by ensuring that the office staff has the most current/valid insurance card on file. I further understand that all co-payments are due at time of service and I am also responsible to pay other amounts due; these amounts may include annual deductibles, charges denied by my insurance company as not covered or not medically necessary, fees for in-office services and/or tests, and any fees incurred should my account require collection action. (E.G. late fees, collection agency, court or attorney costs).

Also please be advised our office may contact you via an automated system, or text messagge, regarding appointments and/or account status. I agree this authorization shall remain valid unless/until I rescind in writing.
Signature Required

The undersigned acknowledges that I have read and understand the above terms and conditions.
Guarantor/Parent/Guardian completing this form (Please Print) *
Date*

MonthDayYear
Date
Guarantor/Parent/Guardian Signature *

Clear
Date

MonthDayYear
Date
Should be Empty:

Patient Registration

Parent / Guardian 1 Information

Parent / Guardian 2 Information

Primary Insurance Information

Secondary Insurance Information

Emergency Contact Information

Patient and Sibling Information