New Patient Paperwork | Surf&Sand Pediatrics

Patient Information & Authorization Form

This is your new patient paper work that is REQUIRED for all new patients. This form should take 5-10 minutes to compelte. Please reach out if you would like to do it in person.

Patient Scetion

Today's Date

Patients Full Name

Patients Birthday

Month

Day

Year

Gender

Male

Female

Address

Phone Number

Parent / Gaurdian Information

Mother's Full Name

Mother's Date of Birth

Mother's Phone Number

Address ( if different than above)

Employer

Father's Full Name

Fathers's Date of Birth

Fathers's Phone Number

Address ( if different than above)

Father's Email

Father's Employer

Insurance information

Primary

Name of Insurance

Card holder Name

Relationship of card holder to patient

DOB of Cardholder

Policy Number

Group Number

Employer

Secondary Insurance ( If applicable )

Name of Insurance

Card holder Name

Relationship of card holder to patient

DOB of Cardholder

Policy Number

Group Number

Employer

HIPPA Contacts

Please list anyone you wish to receive test results, medical, or billing information on your behalf, include anyone you wish to accompany your child to office visits.

Name

Relationship to Patient

Name

Relationship to Patient

Name

Relationship to Patient

How did you hear about us?

Single choice

Referral

Google

Other