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Patient Demographic Information: PEDIATRIC

This is the first form in your medical file. It requests non-medical information about you, as well as emergency and insurance information. When you complete and submit this form on-line, it is immediately stored in the office database. It saves you time at your first appointment, and the doctor can see you more quickly.

* Required Field

1 - Patient







Male Female

Single  Married 
Divorced  Widowed 












 



 

 

2 - Parent | Legal Guardian | Legal Representative






 









 

 




 









 

3 - Billing Responsibility


Mother   Father   Patient   Other  






 







 

4 - Emergency Contact



 




 

5 - Insurance Provider













 

6 - Preferred Pharmacy







 

7 - Certification and Authorization

* By checking the box on the left, I certify that information I have reported about my insurance is correct.
* By checking the box on the left, I authorize the release of any medical information necessary to process my insurance claims.
* By checking the box on the left, I authorize my doctor to apply for benefits on my behalf for covered services rendered by him or her, or by his or her order. I request that payment be made directly to my doctor or to the party who accepts assignment.
* By checking the box on the left, I understand that any co-pays, co-insurance and deductibles deemed my responsibility are payable in full by me.
* By checking the box on the left, I permit a copy of this authorization to be used in place of the original. This authorization may be revoked in writing by either me or my insurance company.
* By checking the box on the left, I have reviewed and understood all written office policies and billing policies of Piga Primary Care Associates.

8 - Click Button to Finalize