New Patient Registration Packet

New Patient Registration

Essex Pediatrics • 89 Main Street, Essex Junction, VT 05452 • (802) 879-6556
Instructions

Complete this form once for each new patient. It contains the following sections:
1. Patient Demographics
2. Parents and Caregivers
3. Medical History

Parents and Caregivers
Parent 1 Name*

First NameLast Name
Parent 1 Date of Birth*

MonthDayYear
Date
Parent 1 Email Address*
example@example.com
Parent 1 Phone Number*
Please enter a valid phone number.
Parent 1 Phone Type*
Parent 2 Name

First NameLast Name
Parent 2 Date of Birth*

MonthDayYear
Date
Parent 2 Email Address*
example@example.com
Parent 2 Phone Number*
Please enter a valid phone number.
Parent 2 Phone Type*
Parents' Marital Status*

MarriedUnmarried, living togetherSeparatedDivorced, joint custodyDivorced, sole custodyOther
Patient's Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Bills Sent To*

First NameLast Name
Billing Address

Billing address is the same as the patient's address
Billing Address*

Street Address

Street Address Line 2

CityState

Zip Code
If one or both parents do not live in the home, who does the child live with? How often does the child see the other parent(s)?
Emergency Contact*

First NameLast Name
Relationship to Patient*
Emergency Contact Phone*
Please enter a valid phone number.
Does anyone other than parents provide care for your child? For example, a relative, nanny, or friend. If so, list additional caretakers here:
Does the child attend daycare? If so, provide details.
Does the child attend school? If so, provide details.

Medical History
Is the patient under 12 months in age?*

YesNo
Describe any health issues for the mother or baby during pregnancy:
Describe any tobacco, drug, or alcohol use during pregnancy:
List any medications used during pregnancy:
Length of Pregnancy*
Number of weeks
Birth*

Vaginal birthCesarean section
Birth Weight*
Hopsital*
Obstetrician*
Describe any health issues the baby had at birth:
Does the patient have any major medical problems for which they are followed by a doctor or specialist?
Has the patient had any surgeries or hospitalizations?
Any emergency room visits over the past year? Concussions, broken bones, or asthma attacks, for example.
I attest that the information I have given on this form is correct and true to the best of my knowledge.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

New Patient Registration