Patient Information
- Full Name: _________________________ Date: __________
- Date of Birth: _____________ Age: _____ Sex: □ M □ F
- Home Address: ________________________________________
- City: _________________ State: _____ ZIP: _____________
Parent/Guardian Information
Primary Guardian
- Name: ________________________ Relationship: __________
- Phone: (Home) _____________ (Cell) _________________
- Email: ____________________________________________
- Address (if different): ________________________________
Secondary Guardian
- Name: ________________________ Relationship: __________
- Phone: (Home) _____________ (Cell) _________________
Insurance Information
- Primary Insurance: __________________________________
- Policy Holder's Name: _______________________________
- Policy Number: ____________________________________
- Group Number: ____________________________________
Medical History
Birth History
- Birth Weight: _________ Weeks Gestation: _____________
- Delivery: □ Vaginal □ C-Section
- Complications: _____________________________________
Immunization Status
□ Up to date □ Delayed schedule □ Records to be transferred
Allergies
- Medications: ______________________________________
- Food: ___________________________________________
- Environmental: ___________________________________
Current Medications
- ________________________ Dose: _________________
- ________________________ Dose: _________________
Emergency Contact
- Name: ___________________________________________
- Relationship: _____________________________________
- Phone: __________________________________________
Consent
I authorize the release of any medical information necessary to process insurance claims and authorize payment of medical benefits to the physician.
Signature: _________________________ Date: __________