Patient Information Form

Please complete the following information about each member in your family if they are members of our practice.


Patient





Date of Birth:

Calendar




Mother/Guardian Information



Date of Birth:
Calendar





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Father/Guardian Information



Date of Birth:
Calendar





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Insurance Information

Please attempt to fill out all information regarding insurance as completely as possible. If there is information that does not pertain to your health insurance plan, please mark "Not Applicable". You will be asked to provide a copy of your insurance card at each visit.:






Effective Date:
CalendarNow



Claims Information





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Secondary Insurance (if applicable)





Effective Date:
CalendarNow



Secondary Insurance Claims





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Emergency Contact




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Other

How did you hear about us? (Please select all that apply.):







Authorization


Assignment of Insurance Benefits: I hereby authorize payment of medical benefits directly to Next Generation Pediatrics. I further authorize the release of any medical information necessary for processing the insurance claim and any referral necessary for the care of the patient. I permit a copy of this authorization to be as valid as the original. I understand that all costs not paid by the insurance will become my responsibility unless otherwise prohibited by state or federal regulations. Permission to Treat a Minor (Under age 18): In the event of an emergency and I cannot be contacted, I give my permission to Next Generation Pediatrics Secure Forms to treat my child in their office or appropriate treatment facility as required by the events of that emergency situation.:

Electronic Signature

By entering my name below, I understand that I am providing an electronic signature which will serve as an affirmation that I'm the parent/legal guardian:





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