Four Seasons Pediatrics, LLC 532 Moe Roadclifton Park, NY12065

Four Seasons Pediatrics, LLC 532 Moe RoadClifton Park, NY12065

Family Last Name ______Today’s Date ______

Address: ______City ______State ____ Zip ______

Please list all children:

Name ______Middle Initial ______DOB ______Sex male / female Allergies ______

What is your preferred number for reminders/ messages ______home cell

Do you want to receive text messages at this number (e.g. your prescription has been sent to the pharmacy)? Yes No

Preferred time for reminders/messages: morning afternoon evening

Maiden Name (the child’s/children’s biological mother) ______Mother’s DOB ______

Parent/Guardian:

Last name______First name ______Middle initial ______

Relationship to the patient: Mother Father Stepmother Stepfather Other ______

DOB: ____ / _____ / _____ male female SS# ______

Home/cell phone: ______Work phone: ______

Address: Same as patient. If not please list address here:

Street: ______City______State ______Zip ______

Other parent/guardian:

Last Name: ______First Name: ______Middle Initial: ______

Relationship to the patient: Mother Father Stepmother Stepfather Other ______

DOB: ____/ ____/ ____ male female SS#: ______

Home/cell phone: ______Work phone: ______

Address: Same as patient. If not please list address here:

Street: ______City______State ______Zip ______

Medical Insurance Information

Primary Insurance ______

Subscriber/policy holder: ______

Policy # ______Group Number: ______Policy Effective Date: ______

Employer: ______Co- Pay/deductible amount $ ______

Secondary Insurance ______

Subscriber/policy holder: ______

Policy # ______Group Number: ______Policy Effective Date: ______

Employer: ______Co- Pay/deductible amount $ ______

E-mail address (for access to the patient portal) ______

Only one e-mail address will have access to the portal (link is on our website), you can also sign up to receive newsletters and notifications through our website: fourseasonspediatrics.com – more than one e-mail address can sign up for this.

Please list your Pharmacy and the location ______

Please list any vision or hearing issues (related to communication) ______

Please answer the following questions:

Race:

American Indian or Alaska Native

Black or African American

White

Other

Ethnicity:

Hispanic

Non – Hispanic

Primary Language:

English

Other ______

I do not wish to Answer

May the doctors have your permission to view prescriptions prescribed outside this office?

Yes

Do your answers apply to all your children?

Yes

Name (print) ______Signature ______

Relationship to patient(s) ______

ABOUT THIS INFORMATION:

Four Seasons Pediatrics PLLC participates in federal programs that report quality of care in health care, as such;we are required to collect information about your child. This information is not reported individually to any other organizations outside of Four Seasons Pediatrics. Your response to these questions is not required and will not be used to affect your care in any way.