2343 Town Center Dr #2, Sugar Land, TX 77478

New Patient Form

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New Patient Form

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Patient Information:

Name

First

Last

Male

Female

Home Address*

City*

State*

Zip Code*

Date of Birth*

Age

Cell Phone Number*

Email address*

Preferred Pharmacy Name*

Preferred Pharmacy Phone Number*

Obstetrician Name

Friend Name

Please Describe

Parents Information and Emergency Contact:

Father's name

First

Last

Date of Birth*

Age

Employer

Ocuppation

Cell Phone*

Email address*

Mothers Name

First

Last

Date of Birth*

Age

Employer

Ocuppation

Cell Phone*

Email address*

Emergency Contact (Other than the parents)

First

Last

Cell Phone

Relationship

Primary Insurance Company

Insurance Name*

Insurance Phone Number*

Insured Party Name*

Group*

ID*

Insurance Phone Number*

I give permission for the following people to seek medical care, on my behalf, for the above listed child

Name

First

Last

Address

City

State

Zip Code

Cell Phone

Relationship

Only the following listed people will be permited to obtain information regarding my child

Name

First

Last

Relationship

Name

First

Last

Relationship

- I Consent to treatment as necessary or desired for the above-named patient, including but not restricted to whatever drugs, medicines, procedures, laboratory, X-Ray, or other studies that may be used by the attending Doctor or his/her qualified designate. - I, also, acknowledge full responsibility for the payment of such services at the time of service unless other arrangements have been made. I understand that my insurance carrier is being billed as a courtesy to me, but should they not pay for these charges I understand that I will assume full financial responsibility. - I authorize the release of any medical or other information necessary to process the insurance claim for services provided to my child. - I also authorize any payment due from my medical insurance to be paid directly to Little Buddies Pediatrics PA. dba Pediatrics of Sugar Land

Signed*

Date*

This field should be left blank