Welcome to Our Practice

Please notify our staff of any changes in your address, phone

or insurance Information

Patient Registration Form

First MI Last M / F

Address

City State Zip Code

DOB Work Phone Home Phone

Emergency Contact and Phone Number

Responsible Party

Mother’s Name: Father’s Name:

Guardian’s Name:_________________________________________________

Address ( if different than above):

City

Home phone ( if different than above)

Work Phone

Cell Phone

Email

Insurance Information

Primary Insurance ID#

Subscriber’s Name and Date of Birth

(if different from above)

Secondary Insurance ID#

Subscriber’s Name and Date of Birth

(if different from above)

The above information will be used for billing purposes only and will not be shared with anyone else.

I authorize the release of any medical information necessary to process my claim and payment for

medical benefits to Healthy Steps Pediatrics, LLC.

________________________________________ _______________________

Signature of Parent/ Responsible Party Date

Thank you for your cooperation and for choosing Healthy Steps Pediatrics, LLC