New Patient Registration Form kidsfirstraleigh com

New Patient Registration Form Kidsfirstraleigh Com-PDF Download

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Emergency Contact Other than Parent,Name Relationship. Home Phone Cell Phone, PLEASE LIST ALL PERSONS WHO MAY SCHEDULE APPOINTMENTS CALL FOR MEDICAL ADVICE OR BRING YOUR CHILD. TO THE OFFICE FOR TREATMENT I E GRANDPARENTS BABYSITTER AUNT THESE INDIVIDUALS WILL BE ASKED TO. PRESENT IDIENTIFICATION AT THE TIME OF THE VISIT IF SOMEONE OTHER THAN THESE PERSONS CONTACTS US. RELATIVE TO YOUR CHILD WE WILL CONTACT THE PARENT OR GUARDIAN FOR PERMISION TO TREAT OR ADVISE IN. THE EVENT OF AN EMERGENCY WE WILL TREAT AND MAKE EVERY ATTEMPT TO CONTACT THE PARENT OR. NAME RELATIONSHIP PHONE NUMBER,Additional Information. Preferred Language,Preferred Provider,Pharmacy Name. Pharmacy Address,Pharmacy Phone Number,Authorization.
As a courtesy Kids First Pediatrics will verify and file insurance but the practice cannot guarantee payment I. understand that I am financially responsible for services rendered as and when charges are incurred I hereby authorize Kids. First Pediatrics and or the rendering physician s to release all medical information required by my insurance company to file. claims for medical benefits I authorize payment of all applicable benefits directly to Kids First Pediatrics of Raleigh. Uses of Protected Health Information to Contact You. We may use your protected health information to contact you by phone or via e mail at home or any other location. that you may specify and leave a message regarding appointment reminders insurance items and any calls pertaining to your. child s clinical care including lab and x ray results with information about treatment alternatives or other health related. benefits and services that in our opinion may be of interest to you. This authorization will remain in effect until revoked by me in writing A photocopy is to be considered as valid as the. Consent to release information acquired in the course of examination and or treatment in regards to treatment. payment of services and operations is understood and explained to you in the posted Notice of Privacy Practices. Parent Guardian Signature Date,Medical History Form. General Questions,How did you hear about us Please Circle One. Family Member Friend Internet Advertisements Hospital Referred Other. Are you the child s Please Circle One, Mother Father Grandparent Foster Parent Other Relative Other Self Are you the patient. Yes No I Don t Know Explanation,Do you consider your child to. be in good health,Does your child have any,serious illnesses or medical.
conditions,Do you have any concerns,about your child s behavior or. development,Is your child in daycare,Is your child in school What type. Do you feel your family has,enough to eat,Birth History. Yes No I Don t Know Explanation,Were there any prenatal or. neonatal complications,Was a NICU stay required,During pregnancy did mother.
use tobacco,During pregnancy did mother,drink alcohol. During Pregnancy did mother,use drugs or medications. During pregnancy did mother,take prenatal vitamins. Social History, Where is your child currently living Please Circle One. In a house or apartment with family In a house or apartment with relatives or friends. In a house or apartment with foster family Shelter Other. How many times have you moved in the past year Please Circle One. 0 1 2 3 4 5 or more,Yes No I Don t Know,Does your child live with both of.
his her parents,Do you feel your child lives in a safe. Are there pets in the child s home,Are there smoke alarms in the child s. Are there any guns in the child s home,Does anyone in your household. smoke Cigarettes E cigarettes or,Always Often Sometimes Rarely Never Not. Applicable,How often does your,child wear a helmet.
when riding a bicycle,How often does your,child wear a seatbelt. How often does your,family eat meals,How often do you read. bedtime stories to your,Biological Family History, Please place an X in the box if the listed relative has ever been diagnosed with the following medical. conditions, Mother Father Siblings Grandparents Other Relatives. High Cholesterol,Heart Disease,High Blood Pressure.
Learning Problems,Mental Illness,Kidney Disease,Liver Disease. Other Concerns,Past Medical History, o Reactive Airway Disease o Other Problems with o Metabolic or Genetic Disorder. ears hearing,o Wheezing o Cystic Fibrosis,o Frequent Headaches. o Bronchitis,o Seizures,o Bleeding Problem,o Bronchiolitis. o Cerebral Palsy,o Blood Transfusion,o Pneumonia,o Other Neurologic.
o Other Breathing Problems Problems,o Seasonal Allergies o Heart Murmur. o Eczema o High Blood Pressure,o Bone Marrow Transplant. o Chronic Skin Problems o Other Heart Problems,o Chemotherapy. o Allergy to bees o Obesity,o Allergy to peanuts o Diabetes. o Sleep Apnea, o Other Allergy Problems o Frequent Abdominal Pain.
o Other Sleeping Problems,o Broken Bones o Constipation requiring. o Concussion doctor s visits o Mood Problems,o Needed Stitches o Kidney Infection o Anxiety. o In a Car Accident o Bed wetting after 5 years o Depression. o Other Injury old o Other Behavioral Problems, o Dental Decay o Recurrent Urinary Tract o Speech Delay. o Problems with eyes or vision Infections o Developmental Delay. o Wears Glasses o Urologic Malformation o Uses Alcohol Drugs. o Wears Contact Lenses o Other kidney or urologic o Uses Tobacco Products. Microsoft Word New Patient Registration Form docx Created Date 8 4 2015 7 42 20 PM

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