Pediatric Registration

Pediatric Registration (Age 0-17)

New or Existing

New Patient
Existing Patient

Patient (Child's) Information

First Name *

First Name

Middle Name

Last Name *

Last Name

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email Address

Primary Language *

Date of Birth *

Social Security Number

Interpreter Needed

Yes
No

Gender at Birth

Female
Male

Home Phone

Cell Phone

Other Phone

Home Phone - Send Reminder?

Send Reminder Calls/Text

Cell Phone - Send Reminder?

Send Reminder Calls/Text

Other Phone - Send Reminder?

Send Reminder Calls/Text

Race (Check all that apply) *

Ethnicity *

Hispanic/Latino
Non-Hispanic/Non-Latino

Is patient employed? (Check any that apply)

Full Time
Part Time
Permanent
Temporary

Is patient currently a student?

Full-time Student
Part-time Student

Parent/Guardian Information

Primary Parent Marital Status

Living Situation of Primary Parent/Guardian

Parent/Guardian Responsible for Payment (Guarantor)

Name

Guarantor Address

Address Line 1

Address Line 2

City

State

Zip Code

Guarantor Email Address

Email Address

Guarantor Primary Language

Preferred Language

Guarantor Date of Birth

Date of Birth

Guarantor Social Security Number

Social Security Number

Guarantor Relationship to Patient

Relationship to Patient

Guarantor Home Phone

Home Phone

Guarantor Cell Phone

Cell Phone

Guarantor Other Phone

Other Phone

Parent/Guardian Employment Status

Employer Information

Name

Guarantor Employer Address

Address

Guarantor Employer Phones

Phone(s)

Second Parent/Guardian/Emergency Contact (Optional)

Name

Secondary Parent Address

Address Line 1

Address Line 2

City

State

Zip Code

Second Parent Email Address

Email Address

Second Parent Relationship to Patient

Relationship to Patient

Second Parent Preferred Language

Preferred Language

Second Parent Home Phone

Home Phone

Second Parent Cell Phone

Cell Phone

Second Parent Other Phone

Other Phone

Second Parent/Guardian Employment Status (Optional)

Employer Information

Name

Second Parent Employer Address

Address

Second Parent Employer Phones

Phone(s)

History Of Applying For Medicaid

Does your child have Medicaid?

Yes
No

If your child does NOT have Medicaid, have you ever applied?

Yes
No
N/A

Medical Insurance Information

Do you currently have any medical insurance?

Yes
No

Medical Insurance Name

*If card presented to front desk staff, skip below

Medical Insurance - Policy Number

Policy Number

Medical Insurance - Address

Address

Medical Insurance - Group Number

Group Number

Medical Insurance - Phone Number

Phone Number

Dental Insurance Information

Do you currently have any dental Insurance?

Yes
No

Dental Insurance Name

*If card presented to front desk staff, skip below

Dental Insurance - Policy Number

Policy Number

Dental Insurance - Address

Address

Dental Insurance - Group Number

Group Number

Dental Insurance - Phone Number

Phone Number

Vision Insurance Information

Do you currently have any vision insurance?

Yes
No

Vision Insurance Name

*If card presented to front desk staff, skip below

Check this box only if you DECLINE applying for the Sliding Fee Application (discounted rates dependent on income)

Additional File Uploads

Click or drag files to this area to upload. You can upload up to 6 files.

You may upload a picture of your insurance card or photo ID as well as items needed to apply for discounted care.

When form is complete, please click Submit below.

Email *