Patient Information Sheet printable pdf download

PATIENT INFORMATION SHEET

DATE:_______________________

PATIENT NAMES:____________________________D.O.B.________________________

_____________________________________________D.O.B.________________________

PATIENT ADDRESS:________________________________________________________

____________________________________________________________________________

MOTHER’S NAME:__________________________ FATHER’S NAME:_____________________

ADDRESS:___________________________________ADDRESS:____________________________

_____________________________________________ ____________________________

PHONE (HOME)______________________________PHONE

(HOME)_______________________

PHONE (WORK)______________________________PHONE

(WORK)_______________________

CELL PHONE_________________________________CELL

PHONE_________________________

NAME OF

CAREGIVER/NANNY/GUARDIAN/BABYSITTER:_____________________________

NAME OF PRIMARY INSURANCE

HOLDER____________________________________________

INSURED DATE OF

BIRTH____________________________________________________________

EMPLOYER_______________________________________________________________________

SOCIAL SECURITY

NUMER___________________________________________________________

INSURANCE COMPANY

NAME________________________________________________________

PLEASE SUPPLY US WITH ANY OTHER ADDRESS OR TELEPHONE INFORMATION

THAT WILL HELP US TO CARE FOR YOUR CHILDREN. THANK YOU.

I AUTHORIZE THE CHILDREN’S MEDICAL GROUP TO RELEASE ANY MEDICAL

INFORMATION TO PROCESS INSURANCE CLAIMS AND AGREE TO PAY FOR ANY

NON-COVERED SERVICES ACCORDING TO THE TERMS OF MY INSURANCE POLICY.

IF I DO NOT PRESENT MY PROOF OF INSURANCE COVERAGE IN A TIMELY MANNER

(30 DAYS) I UNDERSTAND I WILL BE RESPONSIBLE FOR PAYMENT IN FULL

SIGNATURE______________________________________________________________________

Patient Information Sheet