New Patient Intake Form

Patient Last Name

Please complete this field.

Patient First Name

Please complete this field.

Middle Initial

Please complete this field.

Preferred Name

Please complete this field.

SS#

Please complete this field.

Date of Birth

Please complete this field.

Sex

Please complete this field.

Address

Please complete this field.

Cell Phone #

Please complete this field.

Home Phone #

Please complete this field.

Work Phone #

Please complete this field.

Preferred methods of communication (for appt reminder only)

Please select an option.

Patient Race

Please select an option.

Patient Ethnicity

Please select an option.

Is this a foster child?

Please select an option.

If yes, Primary Caregiver/Legal Guardian’s Name

Please complete this field.

Relation

Please complete this field.

Responsible Party Info: (if patient is a minor):

Name

Please complete this field.

SS#

Please complete this field.

Relationship to Patient

Please complete this field.

Cell Phone #

Please complete this field.

Home/Work Phone #

Please complete this field.

Does the patient have Medical Insurance coverage?

Please select an option.

Primary Insurance Company

Please complete this field.

Policy Holder Name and Date of Birth

Please complete this field.

Policy Number

Please complete this field.

Secondary Insurance Company and Policy Number

Please complete this field.

Preferred Primary Care Physician

Please complete this field.

Preferred Pharmacy

Please complete this field.

Pharmacy Address

Please complete this field.

Insurance card

Click to upload files

By signing this form, I certify that I have the legal authority to submit this packet and all information submitted is true to the best of my knowledge.

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Name of Parent / Legal Guardian

Please complete this field.

Date

Please complete this field.

Subscribe to updates from New Beginnings Pediatrics