Patient Registration Form

Patient Information

Child's Name

Nickname

Birthdate

Sex

Male Female

Address same as below

Yes No

If different, please specify

Please fill up below if more than one child

Child's Name

Nickname

Birthdate

Sex

Male Female

Address same as below

Yes No

If different, please specify

Provider

Dr. Dudley Dr. Shepard

Mother

Name

DOB

Address

City/Zip

Preferred Phone

Alternative Phone

Employer

Employer Phone #

Father

Name

DOB

Address

City/Zip

Preferred Phone

Alternative Phone

Employer

Employer Phone #

Ethnicity

Hispanic Not Hispanic Declined

Race

White Black Asian Other Declined

Preferred Language for reminders

English Spanish Creole

Preferred contact # for appointment reminders

Text

Call

Emergency Contact (other than parents)

Name

Relationship to Patient/s

Contact #

Patient Portal

We welcome you to plase sign up for "MY KID'S CHART", our patient portal, where you can securely communictae with doctors and staff, view and print your child's medical record? We will e-mail you the link so you can sign up.

Please Provide E-mail

Preferred Pharmacy Name

Pharmacy Phone

Insurance Information

Primary Insurance Policy Name

Policy holder's Name

Date of Birth

Policy holder's Employer

Insurance holder's Address(if different from above)

Primary Insurance Policy #

Group #

Insurance Address

Phone #

Short text field

Any Secondary Insurance?

Yes No

If yes, Plan & Policy #

Authorization For Release of Medical Records

I authorize the doctor to release any medical information including diagnosis, x-rays, test results, reports, and records pertaining to any treatment or examination rendered to me. I understand that this medical information may be used to any of the following purposes: Diagnostic, insurance, legal and at times when the Doctor deems it necessary in order to ensure the best medical care on my behalf.

I further understand that any person(s) that receive these medical recordsa will not release any of the medical information obtained by this authorization to any other person or organization without a further authorization signed by me for release of the information.

I authorize the release of any medical information necessary to process and claim. I permit a copy of the authorization to be used in place of original. This authorization may be revoked by either me or my insurance at any time in writing.

Your physician has remote access to the electronic medical record of the NCH Healthcare System and can view any testing or treatments provided to you at an NCH facility. Your permission is required to allow your physician remote access to your medical records.

Insurance Policy

Insurance provides for your reimbursement on allowed medical charges. We will be happy to submit to most insurance carriers, if you have provided us with policy numbers, address, place of employment and any other patient information.

I have read the above and accept financial responsibility in full for this account.

Signature

Date

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