Test Patient Intake Form - Patient Intake

Pediatric New Patient Intake Form /Pediatric New Patient Intake Form /Pediatric New Patient Intake Form

Parent / Legal Guardian 2 (if applicable)

Full Name:

Date of Birth:

Relationship to Child:

Occupation:

Phone:

Email:

Insurance Information – Primary

Insurance Company:

Policy Holder Name:

Policy Holder DOB:

Member ID:

Group #:

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Insurance Information – Secondary (if applicable)

Insurance Company:

Policy Holder Name:

Policy Holder DOB:

Member ID:

Group #:

Upload Your Secondary Insurance ID Accepted file types: .pdf,.doc,.docx,.jpg,.jpeg,.png

Pediatric New Patient Intake Form /Pediatric New Patient Intake Form /Pediatric New Patient Intake Form

Consent for Treatment

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Child Name:

Guardian 1 Signature:

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Date

Guardian 2 Signature:

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Date

Financial Policy

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Responsible Party Signature:

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Date

Authorization for Release of Medical Records

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Scottsdale Office – 5425 East Bell Road, Suite 131, Scottsdale, Arizona

Glendale Office – 5750 West Thunderbird Road, Suite F620, Glendale, Arizona 85306

Previous Pediatrician/Practice:

Signature:

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Date:

HIPAA Notice of Privacy Practices & Acknowledgment

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Child Name:

Parent/Guardian Signature:

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Date:

(CID : 18022)

New Patient Intake Form

New Patient Intake Form

Pediatric New Patient Intake Form /Pediatric New Patient Intake Form /Pediatric New Patient Intake Form

IMPORTANT INSURANCE NOTICE IMPORTANT INSURANCE NOTICE /IMPORTANT INSURANCE NOTICE /IMPORTANT INSURANCE NOTICE

Child Information

Parent / Legal Guardian 1

Pediatric New Patient Intake Form /Pediatric New Patient Intake Form /Pediatric New Patient Intake Form

Parent / Legal Guardian 2 (if applicable)

Insurance Information – Primary

Insurance Information – Secondary (if applicable)

Pediatric New Patient Intake Form /Pediatric New Patient Intake Form /Pediatric New Patient Intake Form

Social History

Medical History

Birth History

Immunizations

Pediatric New Patient Intake Form /Pediatric New Patient Intake Form /Pediatric New Patient Intake Form

Consent for Treatment

Financial Policy

Authorization for Release of Medical Records

HIPAA Notice of Privacy Practices & Acknowledgment

New Patient Intake Form

New Patient Intake Form

Pediatric New Patient Intake Form /Pediatric New Patient Intake Form /Pediatric New Patient Intake Form

IMPORTANT INSURANCE NOTICE IMPORTANT INSURANCE NOTICE /IMPORTANT INSURANCE NOTICE /IMPORTANT INSURANCE NOTICE

Child Information

Parent / Legal Guardian 1

Pediatric New Patient Intake Form /Pediatric New Patient Intake Form /Pediatric New Patient Intake Form

Parent / Legal Guardian 2 (if applicable)

Insurance Information – Primary

Insurance Information – Secondary (if applicable)

Pediatric New Patient Intake Form /Pediatric New Patient Intake Form /Pediatric New Patient Intake Form

Social History

Medical History

Birth History

Immunizations

Pediatric New Patient Intake Form /Pediatric New Patient Intake Form /Pediatric New Patient Intake Form

Consent for Treatment

Financial Policy

Authorization for Release of Medical Records

HIPAA Notice of Privacy Practices & Acknowledgment

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