PEDIATRIC INTAKE FORM

New Pediatric Patient Form

Demographics of Patient

Financially Responsible Party Information if different than the Parent or Guardian
City
State/Province
Zip/Postal
Country
Please List Primary Medical Doctor
City
State/Province
Zip/Postal
Country

HIPPA PRIVACY REGULATION

Consent For Treatment Of A Minor Child

3rd Party Payment or Reimbursement Information

Insured's Address if different than parent or guardian
City
State/Province
Zip/Postal
Country
Insurance Company and Address
City
State/Province
Zip/Postal
Country

Health History

School Age Children

Pre School or Infants

Developmental Milestones (only for pre school or infants): When did your child first achieve the following milestones?

INFORMED CONSENT

Sending