Welcome Form

WELCOME TO OUR PRACTICE

Patient Name:

Form Completed By/Relationship to Patient:

Birth Date:

Age:

Today’s Date:

MaleFemale

Patient Social Security Number:

Home Phone Number:

Primary Address:

City:

State:

Zip:

Parent #1 Cell Number:

Parent #2 Cell Number:

Parent #1 Work Number:

Parent #2 Work Number:

Email Address:

Fax Number:

Referred By:

HOUSEHOLD

Please list all those living in the child’s house

Name:

Relationship to Child:

Birth Date:

Heath Problems:

Name:

Relationship to Child:

Birth Date:

Heath Problems:

Name:

Relationship to Child:

Birth Date:

Heath Problems:

Are there siblings not listed? If so, please list their names ages and where they live:

If Parent #1 and Parent #2 are not living together, or if child does not live with parent, what is the child’s custody status?

If one or both parents are not living in the home, how often does he/she see the parent(s) not in the home?

BIRTH HISTORY

DEVELOPMENT

Are you concerned about your child’s physical development? YesNo

Explain:

Are you concerned about your child’s mental or emotional
development? YesNo

Explain:

Are you concerned about your child’s attention span? YesNo

Explain:

If your child is in school:

What Grade?

Name of School:

How is his/her behavior in school?

Has he/she failed or repeated a grade in school?

How is he/she doing in academic subjects?

Is he/she in special or resources classes?

Additional family history:

OTHER MEDICAL SPECIALISTS

Please list any other medical specialists that your child sees

Name:

Type of Specialty:

Name:

Type of Specialty:

Name:

Type of Specialty:

Name:

Type of Specialty:

AUTHORIZATION FOR TREATMENT

In the event that I, (name of parent/guardian) am unable to accompany my child/children listed above, I authorize the following individual(s) to give permission for minor treatments in my absence:

Name:

Relationship:

Name:

Relationship:

Name:

Relationship: `

Name:

Relationship:

EMERGENCY CONTACT INFORMATION

Name:

Relationship to Child:

Phone Number Best to Be Reached at:

PHARMACY INFORMATION

Pharmacy Name:

Address:

Phone Number:

INSURANCE INFORMATION

Name of Insurance:

ID#:

GRP#:

Policy Holder Name:

Employer:

Employer Address:

Current Pediatrician:

Tel#:

WELCOME TO OUR PRACTICE

HOUSEHOLD

BIRTH HISTORY

GENERAL

DEVELOPMENT

If your child is in school:

FAMILY HISTORY

Have any family members had the following:

PAST HISTORY

Does your child have or has he/she ever had:

OTHER MEDICAL SPECIALISTS

Please list any other medical specialists that your child sees

AUTHORIZATION FOR TREATMENT

EMERGENCY CONTACT INFORMATION

PHARMACY INFORMATION

INSURANCE INFORMATION

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