Birth Date: Age: Home Address: City: State: Zip: Primary Phone Number: Home Home Cell Cell
School: Grade: List any sports or extracurricular activities:
Name: Birth Date: Address (if different): City: State: Zip Code:
Phone Number (if different): Phone Number Home Cell
E-mail Address:
Employer's Name: Occupation:
Phone Number (if different): Phone Number Phone Number (if different): Home Cell
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.
I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.
I understand that where appropriate, credit bureau reports may be obtained.