Form New Patient Registration Form New Patient Registration e-Form Put an X in All Boxes That Don't Apply to You.Our Electronic Medical Records (EPIC) require the following information, in its entirety, to successfully complete your child's chart. *Please complete ALL boxes. Put an X in the box if it doesn't apply to you. PATIENT INFORMATION:Today's Date MM slash DD slash YYYY Patient's Full Name(Required) First Middle Last Patient Likes to be Called: Date of Birth(Required) MM slash DD slash YYYY Gender Assigned at Birth(Required) Male Female Gender Identity if different than "At Birth" Patient Address(Required) Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone(Required)Other PhonePHARMACY INFORMATION:Preferred Pharmacy(Required)Phone(Required)Pharmacy Address(Required) Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code SIBLING INFORMATION: Does the Patient Have Siblings? Yes (list names below) No SiblingsFirst NameLast NameDate of BirthGender Add RemoveINSURANCE POLICY HOLDER INFORMATION: Does the Patient Have Insurance? Yes No Policy Holder Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Relationship to PatientPolicy Holder Address(Required) Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Policy Holder's Employer(Required)Insurance Company(Required)Insurance Claims Address(Required) Street Address or PO Box City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Policy/ID#(Required)Group #(Required)PARENT/GUARDIAN INFORMATIONDo all parents and/or legal guardians reside in the same household together with the patient?(Required) Yes No Please complete the following information fields for all parents/legal guardians even if they do not reside in the household together.PARENT/GUARDIAN #1(Required) First Last Legal Guardian to Patient?(Required) Yes No Relationship to Patient(Required)Date of Birth(Required) MM slash DD slash YYYY GenderEmail Primary Phone(Required)Other PhoneIs There Another Parent/Guardian?(Required) Yes No PARENT/GUARDIAN #2(Required) First Last Legal Guardian to the Patient?(Required) Yes No Relationship to the Patient(Required)Date of Birth(Required) MM slash DD slash YYYY GenderEmail Primary Phone(Required)Other Phone
