Registration Form for patients under 18 years old

Personal Information
Patient's Name *
Patient's Name
Mailing Address
Mailing Address
Sex
Date of Birth
Date of Birth
Home Phone
Home Phone
Cell Phone
Cell Phone
Work Phone
Work Phone
Contact Preferred
Parent Information:
Parent 1: Name
Parent 1: Name
Phone
Phone
Phone Number
Phone Number
If parents are divorced or separated please fill out this section
Are there any legal restrictions that would restrict the non-custodial parent from consenting to medical treatment for the child, or from obtaining information about the child's medical treatment?
If parents are divorced or separated, please fill out this section
Are there any legal restrictions that would restrict the non-custodial parent from consenting to medical treatment for the child, or from obtaining information about the child's medical treatment?
INSURANCE INFORMATION
Policy Holder's Date of Birth (If other than patient)
Policy Holder's Date of Birth (If other than patient)
Policy Holder's Date of Birth (If other than patient)
Policy Holder's Date of Birth (If other than patient)
As legal guardian of the patient, I hereby confirm that all of the above information is correct