Child Patient Information

Child Registration Form
* required field

Patient Information

Primary Phone Number

Parent/Guardian Information

Parent's Marital Status
Relation to Patient

Phone Number
Secondary Phone Number

Relation to Patient

Phone Number
Secondary Phone Number

Emergency Contact Information

Insurance Information

Medical History

Does child have a Primary Care Doctor?
Is child currently being treated by any other physicians?

How did you hear about our Practice?
Does child have any allergies/sensitivities to medications or latex?
Is child currently taking any prescription or over-the-counter medications?
Does child take vitamins?

Does child live in a home with indoor smokers?
Indoor pets?
History of major illness?
Has the child been hospitalized, had any surgeries or been to the ER recently?

Has puberty and/or menstruation begun?


I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status. I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims and to any Physician or Health Care Provider to whom my child might be referred for medical reasons. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child.

Security Measure