patıent regıstratıon - Amazing Kids Pediatrics

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patıent regıstratıon - Amazing Kids Pediatrics
PATIENT REGISTRATION
PATIENT INFORMATION
INSURANCE INFORMATION
Last Name: ___________________________________
Primary Insurance: _____________________________
First Name: ___________________________________
ID/Policy No.: _________________________________
Middle Name: _________________________________
Group No.: ___________________________________
Gender (M/F): ________________________________
Plan: ________________________________________
Date of Birth: _________________________________
Insured’s Name: _______________________________
Address: _____________________________________
Insured’s DOB: ________________________________
_____________________________________________
Insured’s Address: _____________________________
_____________________________________________
_____________________________________________
Social Security #: ______________________________
Social Security #: ______________________________
Relationship to Patient: _________________________
Name of Parent/Legal Guardian: __________________
Employer: ____________________________________
Home Phone: _________________________________
Effective Date: ________________________________
Work Phone: __________________________________
Cell Phone: ___________________________________
Secondary Insurance: ___________________________
ID/Policy No.: _________________________________
e-mail: _______________________________________
Group No.: ___________________________________
Plan: ________________________________________
Insured’s Name: _______________________________
Insured’s DOB: ________________________________
Insured’s Address: _____________________________
_____________________________________________
Social Security #: ______________________________
Relationship to Patient: _________________________
Employer: ____________________________________
Effective Date: ________________________________
Date: ___________________________
PATIENT INFORMATION
Patient Name: _______________________________________
Gender (M/F): _______________________________________
Date of Birth: ________________________________________
Past Medical History:
Chronic Medical Illness: (i.e.: Allergies, Asthma, Diabetes, Heart Murmur) ________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_________________________________________________________________________________
Hospitalizations/Surgeries: ______________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Drug /Food/Insect Allergies: _____________________________________________________________
_______________________________________________________________________________________
___________________________________________________________________________________
Type of Reaction: ______________________________________________________________________
_____________________________________________________________________________________
Current Medications and Dosage: _________________________________________________________
_______________________________________________________________________________________
___________________________________________________________________________________
Page
2
Family Medical History: Has any member of your family had the following? Please circle the family
member. (M-mother of patient; F-father of patient; MGM-maternal grandmother; MGF-maternal
grandfather; PGM-paternal grandmother; PGF-paternal grandfather; SIBS-siblings of patient
Asthma/Allergies
Anemia/Bleeding Disorders
Cancer
Diabetes
Eczema/Skin Disease
Heart Disease (before age 60)
High Cholesterol
Hypertension
Mental Illness
M
M
M
M
M
M
M
M
M
F
F
F
F
F
F
F
F
F
MGM
MGM
MGM
MGM
MGM
MGM
MGM
MGM
MGM
MGF
MGF
MGF
MGF
MGF
MGF
MGF
MGF
MGF
PGM
PGM
PGM
PGM
PGM
PGM
PGM
PGM
PGM
PGF
PGF
PGF
PGF
PGF
PGF
PGF
PGF
PGF
SIBS
SIBS
SIBS
SIBS
SIBS
SIBS
SIBS
SIBS
SIBS

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