Child Patient Registration

Complete the secure registration form for patients up to age 14.

Step 1 of 4Child & Guardians

Child & GuardiansMedical HistoryDental HealthFinancial & Insurance

Patient Health Record

Child's name *

Age

Date of birth

Social Security number

Guardian 1

Name

Relationship to patient

Home address

City

State

Zip

Home phone

Work phone

Cell phone

Email

Birth date

Social Security number

Where do you prefer to receive calls?

Home

Work

Cell

Guardian 2

Name

Relationship to patient

Home address (if different)

City

State

Zip

Home phone

Work phone

Cell phone

Email

Birth date

Social Security number

Where do you prefer to receive calls?

Home

Work

Cell

Insurance Information

Insurance company

Policy number

Group number

Insured's ID number

Insured date of birth

Address for insurance submission

Spouse employer

Spouse insurance company

Visit and Responsible Party

Who will bring the child to the office and their cell number?

Will the child be driving themselves?

Yes

No

Responsible financial party

Insurance subscriber

How Did You Find Us?

Billboard

Church Bulletin

Pinecrest Academy

Website

Direct Mail

Whom may we thank for referring you?

Referral type

Patient

Other