babydochousecalls.com - PATIENT REGISTRATION FORM

PATIENT REGISTRATION FORM
Patient Name:

First NameLast Name
DATE:

MonthDayYear
Date
Date of Birth:

MonthDayYear
Date
Sex:

MaleFemale
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother’s Name:
Mother’s E-mail:
example@example.com
Mother’s Home Phone:

Area CodePhone Number
Mother’s Cell Phone:

Area CodePhone Number
Father’s Name:
Father’s E-mail:
example@example.com
Father’s Home Phone:

Area CodePhone Number
Father’s Cell Phone:

Area CodePhone Number
SIBLINGS:
I understand that payment for all medical care is due at time of service. The parent and/or legal guardian who signs this form is responsible for any and all payments and fees, regardless of marital status. I understand that I am responsible for any costs incurred in the collection of a patient’s account in case of default, including reasonable attorney fees and court costs. I understand that Baby Doc House Calls does not accept any insurance and that submission of a claim to insurance is my responsibility, and that coded claim forms will be provided upon request. I understand that if I have any form of Medicaid coverage, a claim form should not be requested or submitted. I understand that outside services such as, but not limited to, outside laboratories, imaging companies and hospitals are not included in the fee and may bill you or your insurance company separately.
Parent/Guardian Signature:

Clear
Date:

MonthDayYear
Date
X
I hereby grant permission to Andrea C. Goings, M.D. and associates of Baby Doc House Calls to release any pertinent information to my insurance company upon request from my insurance company
Parent/Guardian Signature:

Clear
Date:

MonthDayYear
Date
X
I give Andrea C. Goings, M.D. and associates of Baby Doc House Calls permission to treat my child for this and future appointments. I understand that not all medical issues can be appropriately managed in a House Call setting, and that all treatment options and decisions will be discussed with the physician at the time of service.
Parent/Guardian Signature:

Clear
Date:

MonthDayYear
Date
X
CANCELLATION POLICY: Baby Doc House Calls requires at least 24 hours-notice prior to a cancellation. A cancellation with less than a 24-hour notice will incur the full cost of the visit. Visits booked on weekends and holidays require a 48-hour cancellation notification.

OPTIONAL:
I give permission to Andrea C. Goings, M.D. and associates to communicate with me via SMS/Face time/Email. I understand that these are not secure or encrypted transmissions. I will not hold Dr. Andrea C. Goings, M.D., or associates liable for any breach of privacy that may occur due to breach of confidentiality via SMS/Face time/Email.
Parent/Guardian Signature:

Clear
Date:

MonthDayYear
Date
X
Should be Empty: