Edgewood Center Pediatrics

Family Demographic Form (please fill out each section completely)

Today's Date:

First and last name of child

Date of Birth:

Who does patients live with? MOM/DAD/BOTH/OTHER:

Parent/Guardian

Last Name:

First Name:

Date of Birth:

Relationship to patient:

Address:

City:

State:

Zip Code:

Phone: (home or cell?)

Primary/Secondary? Email address:

Parent/Guardian

Address same as above:

Last Name:

First Name:

Date of Birth:

Relationship to patient:

Address:

City:

State:

Zip Code:

Phone: (home or cell?)

Primary/Secondary? Email address:

NOTICE AND ACKNOWLEDGEMENT OF PRIVACY NOTICE

Acknowledgement:

I acknowledge that I received the Notice of Privacy Practices

Patient or parent/guardian

Printed Name

Date

RELEASE AND ASSIGNMENT

The information that I have given is correct to the best of my knowledge. I understand that it will be held in the strictest confidence, and it is my responsibility to inform this office of any changes in my minor/child’s health status.

If my child is covered by health insurance, I assign Edgewood Center Pediatrics all insurance benefits and understand that if services rendered are not covered by my health plan, I am financially responsible for all charges. I hereby authorize Edgewood Center Pediatrics to release all information necessary to secure payment of benefits. I authorize the use of this signature on all insurance submissions whether medical or electronic.

Patient or parent/guardian

Typed Name

Date

Please upload the front and back of the parent/guardian state issued ID

Front

Back