Form - Patient Registration | Dr. Okezie Pediatrics | Pediatric, Child Doctor

Patient Registration Form

Patient Information
First name*
Last Name*
Date of Birth*
MM slash DD slash YYYY
Gender*
Social Security Number*
Relationship to Guarantor*
Pharmacy (Name & Street)
Lives With*
Mother / Step-Mother / Guardian Information
Relation to Patient
First Name*
Last Name*
Date of Birth*
MM slash DD slash YYYY
Driver's License #
Social Security #*
Address*
City*
State*
Zip*
Home Phone #*
Cell Phone #
Work Phone #
Email
Occupation
Employer
Father / Step-Father / Guardian Information
Relation to Patient
First Name*
Last Name*
Date of Birth*
MM slash DD slash YYYY
Driver's License #
Social Security #*
Address*
City*
State*
Zip*
Home Phone #*
Cell Phone #
Work Phone #
Email
Occupation
Employer
Emergency Contact: Non-Parent
First Name*
Last Name*
Phone #*
Relation*
Primary Insurance
Secondary Insurance
Insurance Company*
Insurance Company
Insurance ID #*
Insurance ID #
Subscriber's Name*
Subscriber's Name
Date of Birth*
MM slash DD slash YYYY
Date of Birth
MM slash DD slash YYYY
Relationship to Patient*
Relationship to Patient
I understand that withholding ANY insurance information is considered insurance fraud.
CONSENT TO TREATMENT AND RELEASE OF INFORMATION
Treatment Consent / Information Release*
- I hereby authorize any physician, practitioner, insurance company, or third party to disclose to each other needed protected information that is relevant to your Childs health to carry out medical treatment, health care operations, payment, or for any other purpose that is permitted or required by law. A photocopy of this authorization shall be the same as the original. I hereby certify the statements hereon and those attached are true and correct to the best of my knowledge. I understand it is fraudulent to fill out this form with information I know to be false or to omit important facts.
FINANCIAL RESPONSIBILITY AGREEMENT BY PERSON OTHER THAN PATIENT
Financial Responsibility*
- I hereby authorize direct payment of surgical/medical benefits for services rendered by Okezie Pediatrics and all other office personnel. I understand that I am financially responsible for any services rendered that may not be covered by my insurance.
Digital Signature*
- I Agree.
Parent Signing*

Patient Registration Form

Patient Information

Mother / Step-Mother / Guardian Information

Father / Step-Father / Guardian Information

Emergency Contact: Non-Parent

Primary Insurance

Secondary Insurance

CONSENT TO TREATMENT AND RELEASE OF INFORMATION

FINANCIAL RESPONSIBILITY AGREEMENT BY PERSON OTHER THAN PATIENT