Patient Registration Form – Child/Minor/Dependent

Child’s Legal Name______-______- ______

LastFirstPreferredMiddleSocial Security Number

______

Street AddressCityStateZip CodeDate of Birth

 Male Female Child lives with: Mother  Father  Both Parents Other______

Home Phone( )______ Contact’s Mobile ( )______ Ok to text you?Yes No Work Phone( )______

Email ______ No e-mail Language spoken: ______

Contact Preference:  Home phone Work phoneMobile phoneMail  Patient Portal Ok to leave a voicemail on phone:  Yes  No

Child’s Race:  African  African-American  American Indian  Asian  Black  Black/African American  Laotian  Other  White

Child’s Ethnicity:  Central American  Cuban  Dominican  Hispanic or Latino/Spanish  Mexican  Not Hispanic or Latino  Puerto Rican  South American  Spaniard

How did you hear about us? ______If friend, whom referred you?______

Mother’s Legal Name______-______- ______

LastFirstPreferredMiddleSocial Security Number

______

Street AddressCityStateZip CodeDate of Birth

Father’s Legal Name______-______- ______

LastFirstPreferredMiddleSocial Security Number

______

Street AddressCityStateZip CodeDate of Birth

Guardian’s Legal Name______-______- ______

LastFirstPreferredMiddleSocial Security Number

______

Street AddressCityStateZip CodeDate of Birth

Emergency Contact(not parent)______(___)______- ______(___)_____ - ______

FirstLast NameRelationshipHome PhoneMobile Phone

Referring Physician (if applicable): ______

Insurance Policy holder: ______

LastFirstRelationship

Address same as patient?  YesIf no, please complete ______

Street AddressCityStateZip Code

Social Security #: ______-______- ______Date of Birth ______ Male  Female

Employer ______

Responsible Party (PERSON TO RECEIVE BILLS AFTER INSURANCE HAS PAID) Mother  Father  Other______

Employment Status: ______

Signature of Patient or Authorized Person: ______Date: ______