Patient Name *Birth DateAgeHome AddressCityStateZipPrimary Phone Number
E-mail AddressSchoolList any sports or extracurricular activitiesSiblings (names and ages)
RelationshipN/AMotherStep-MotherGuardianOther
Employer
Emergency Contact Name (other than parent)Phone NumberRelation to childAddressCityStateZipPerson(s) OK to release appointment or medically related information to concerning child.Relation
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 medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. 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.