Pediatric Patient Information

Pediatric Patient Information
Name*

First NameMiddle Name or InitialLast Name
Nickname
Gender*

MF
Address*

Street Address / PO Box #

Street Address Line 2

CityState

Zip Code
Preferred Phone*
Secondary Phone
Ok to call these numbers and leave a message?*

YesNo
Patient Age*
Birth Date*

MonthDayYear
Date
Is this patient in Foster Care?*

YesNo
Caseworker
Confidential?*

YesNo
Emergency Contact (Other than parents)*
Phone Number*
Please enter a valid phone number.
Primary Doctor/Pediatrician*
PCP Clinic Name*
Address

Street Address / PO BOX

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
If patient was referred, by whom?*
Is this your...

Primary caregiverRegular Eye DoctorSchool NurseOther
If other
Please check the box by each guardian living with patient:
PARENT / GUARDIAN #1*

First NameLast Name
Is this guardian living with the patient?*

YesNo
Relationship to Patient*
SS#*
Date of Birth*

MonthDayYear
Date
Phone*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Employer*
Occupation*
Employer Phone*
Please enter a valid phone number.
Ok to call this number?*
Parent / GUARDIAN #2

First NameLast Name
Relationship to Patient
Is this guardian living with the patient?

YesNo
SS#
Date of Birth

MonthDayYear
Date
Phone
Address

Street Address / PO Box #

Street Address Line 2

CityState

Zip Code
Employer
Occupation
Employer Phone
Please enter a valid phone number.
OK to call this number?
Person responsible for bill*

First NameLast Name
SS#*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
INSURANCE INFORMATION

Must be completed in addition to obtaining a copy of your card
Primary Insurance*
Policyholder's Name*
Assignment of Benefits: I hereby assign to the physician all payments for medical services rendered to my dependents. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all the charges whether or not paid by insurance. I hereby authorize said assignee to release all information necessary to secure payment.
Parent or Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Pediatric Patient Information

INSURANCE INFORMATION