Patient Registration
 
 

Bi-County Pediatrics, P.C.

 

                                                   PATIENT INFORMATION

 

LAST NAME_________________________________ FIRST_____________________________ M.I.______

ADDRESS________________________________________________________________________________

                                NUMBER           STREET                                                               CITY                                               STATE               ZIP

HOME PHONE____________________ BIRTH DATE______________________ SEX________________

SOCIAL SECURITY NUMBER___________________ REFERRED BY _____________________________

 

GUARANTOR INFORMATION

MOTHER

 

LAST NAME____________________________________

FIRST_________________________MI__

ADDRESS ______________________________________

________________________________________________

SS# _______-____-________  BIRTH DATE__________

MARITAL STATUS________ HOME PHONE_______

EMPLOYER:____________________________________

ADDRESS______________________________________

CITY,STATE,ZIP________________________________

WORK PHONE___________________

CELL PHONE____________________ EMAIL__________________________

EMERGENCY CONTACT: (please give name and number)

Name_____________________________________________

Telephone #_______________________________________

Relationship________________________________________

FATHER

 

LAST NAME____________________________________

FIRST_________________________MI__

ADDRESS ______________________________________

________________________________________________

SS# _______-____-________  BIRTH DATE__________

MARITAL STATUS________ HOME PHONE_______

EMPLOYER:____________________________________

ADDRESS______________________________________

CITY,STATE,ZIP________________________________

WORK PHONE___________________

CELL PHONE____________________ EMAIL__________________________

EMERGENCY CONTACT: (please give name and number)

Name_____________________________________________

Telephone #_______________________________________

Relationship_______________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


INSURANCE INFORMATION

 

PRIMARY INSURANCE:                                                           SECONDARY INSURANCE:         _______________________________________________    ________________________________________________

ADDRESS______________________________________    ADDRESS_______________________________________

CITY, STATE, ZIP_______________________________    CITY, STATE, ZIP________________________________

POLICY HOLDER______________________________     POLICY HOLDER_______________________________

DATE OF BIRTH________________________________   DATE OF BIRTH ________________________________

RELATIONSHIP TO PATIENT____________________   RELATIONSHIP TO PATIENT_____________________

POLICY #______________________________________   POLICY #_______________________________________

GROUP #______________________________________   GROUP #________________________________________

 

PLEASE READ:  All professional services are the responsibility of the Guarantor of the patient. Payment is required at the time of each visit. You are responsible for all fees, regardless of insurance coverage.  Insurance information must be current. Any charges not paid for by insurance will be the responsibility of the Guarantor.

 

All office policies have been explained to me and I understand that all fees are my responsibility.

 

 

x________________________________                                        _____________________________________________

    Guarantor                                                                                                            Date