NEW PATIENT REGISTRATION   Account: _________________________
Appointment with Doctor: ______________

Patient Name:

______________________________________________

Date of Birth:

__________________

Sex:

______________

Date:

_______________

Street Address:

______________________________________________

City, State, Zip Code:

_____________________________________

Home Telephone:

___________________

School:

_____________________________________

Referred By:

_________________________________________________________

Father's Name:

_________________________

Employer:

________________

Date of Birth:

__________________

Work Telephone:

___________________

SSN:

_______________

Mother's Name:

_________________________

Employer:

________________

Date of Birth:

__________________

Work Telephone:

___________________

SSN:

_______________

Guardian (other than self):

_________________________

Employer:

________________

Date of Birth:

__________________

Work Telephone:

___________________

SSN:

_______________

Emergency Contact (other than parents):

______________________________________________

Address:

______________________________

Telephone:

_______________

Closest Relative (not at your address):

______________________________________________

Address:

______________________________

Telephone:

_______________
Parents:      Married      Separated        Divorced       Widow/Widower       Single
         
INSURANCE AND BILLING INFORMATION

Person Responsible: Father       Mother       Other: _________________________   Relationship: __________________________

Billing Address (if different from above):

______________________________________________

  

Telephone:

_______________________________
         
*PAYMENT REQUIRED AT TIME OF SERVICE - UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE. *

Insurance Company:

______________________________________________

Address:

______________________________

Effective Date:

___________________

Subscriber's Name:

______________________________________________

I. D. Number:

__________________

Group:

_______________

  

Insurance Company:

______________________________________________

Address:

______________________________

Effective Date:

___________________

Subscriber's Name:

______________________________________________

I. D. Number:

__________________

Group:

_______________

  

Name(s) of other children who are patients of the clinic:

________________________________________________________________________________________________________
ASSIGNMENT OF INSURANCE BENEFITS
I hereby authorize direct payment of surgical / medical benefits to The Pediatric Clinic for services rendered. I understand that I am
financially responsible for any balance not covered by my insurance.
AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize The Pediatric Clinic to release any medical or incidental information that may be necessary to either medical care or
in processing applications or claims for financial benefit.

A photocopy of these assignments shall be valid as the original.

Patient (please print):

______________________________________________

  

Date:

____________________________

Parent / Guardian (please print):

______________________________________________

  

Signature:

______________________________


The Pediatric Clinic
888 Tara Boulevard Baton Rouge, Louisiana 70806
225-926-4400