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Patient Registration Form

Filling your registration details will help you move more quickly through the registration process and to the treatment area on the day of your service. Please fill out all the 8 forms and then click on Send Mail.

PATIENT INFO
   
Patient Full Name *:
 
Date of Birth: Gender(M/F):
 
Home address *:
 
City *: State:
 
Zip: Ethnicity:Non-Hispanic Hispanic Not specified
 
Preferred language:
 
Race:African or African American Asian or Asian American Caucasian or European American Native American or Native Alaskan Native Hawaiian or other Pacific Islander Other race
 

PARENT/ GUARDIAN INFO
 
Parent/Guardian Name *: Relationship to Child *:
 
Birth Date *: Email *:
 
Home address:
 
Phone Numbers(Cell) : (H) : (W) :
 

INSURANCE INFO/ RESPONSIBLE PARTY
 
Insurance company : Group #:
 
Child's ID # : Insurance policy holder's name :
 
Relationship to child :  
 

EMERGENCY CONTACT INFO (not living with patient)
 
Name :  Relationship :   Phone *:
 
I hereby assign the benefits from any insurance or third party to GENTLE PEDIATRICS PLLC for medical services provided to my child. I understand that GENTLE PEDIATRICS PLLC has the right to decline or accept assignment of such benefits. If these benefits are not assigned to GENTLE PEDIATRICS PLLC, I agree to forward to the practice, upon receipt, any insurance or third-party payments I receive for services rendered to me. I authorize the release of any medical information needed to determine the benefits. This authorization will remain valid until I revoke it by written notice. I understand that I am financially responsible for all charges whether or not they are covered by insurance.