Pediatric Paperwork

Today's Date:

Name: (Last, First, MI)

Preferred Name:

Date of Birth

MonthDayYear

Preferred Language:

Height:

Weight:

Gender:

Race:

CMS requires providers to report both race and ethnicity

Ethnicity

Name of current pediatrician

Phone number of current pediatrician

Name of Guardian

First NameLast Name

Relation to the Patient

Home Phone:

Mobile:

Work:

Social Security number:

Email:

example@example.com

Occupation:

Marital Status:

Employer:

Address Information:

Address

Street Address Line 2

CityState

Zip

Does the patient also live at this address? If no, please fill in address of where the patient resides.

Childrens Names and Ages:

Referred by:

Referred by (name):

Full Name and Phone Number:

Relationship:

Please list the name, relation, and phone number of anyone else permitted to bring the patient to future appointments:

Name and Date of Birth of Primary Insurance Holder

Patients Relation to Insured

Please select how you would like for your visits to be billed

Self Pay (Cash)InsurancePersonal Injury/AutoOther

If possible, please attach a picture of the BACK of your insurance card

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If possible, please attach a picture of the FRONT of your insurance card

Browse Files

Name of Primary Insurance:

Name of Secondary Insurance:

Frederick Chiropractic Pediatric Confidential Patient Health History

PATIENT INFORMATION

Guardian Information

EMERGENCY CONTACT INFORMATION

Financial Information

Patient Health History

Patient History

All Set! Select "Submit" below, and we will receive your information. We look forward to meeting you.