New Patient Registration FormBring a copy of your child’s insurance card, immunizations, and guardian’s government-issued ID card. Registration Consents PATIENT INFORMATION Child's Name * First Name Last Name Child's preferred name to be called * Child's birthday * MM DD YYYY Child's sex at birth * Female Male Child's Social Security Number * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country GUARDIAN 1 INFORMATION Guardian 1 Name * First Name Last Name Guardian 1 relationship to patient * Biological mother Biological father Step mother Step father Sibling Aunt or uncle Grandparent Foster parent Guardian Social Worker Other Guardian 1 Birthday * MM DD YYYY Guardian 1 Social Security Number * Guardian 1 home phone number * Type 000-000-0000 if none (###) ### #### Guardian 1 cell phone number * Type 000-000-0000 if none (###) ### #### Guardian 1 email address * Guardian 1 occupation Guardian 1 place of employment GUARDIAN 2 INFORMATION Guardian 2 Name First Name Last Name Guardian 2 relationship to patient Biological mother Biological father Step mother Step father Sibling Aunt or uncle Grandparent Foster parent Guardian Social Worker Other Guardian 2 birthday MM DD YYYY Guardian 2 Social Security Number Guardian 2 cell phone number (###) ### #### Guardian 2 email address Guardian 2 occupation Guardian 2 place of employment Insurance Kaiser / Tricare * Yes, my child does NOT have Kaiser or Tricare insurance. Okay to continue with registration. No, my child DOES have Kaiser or Tricare. Our clinic does NOT accept these insurances. Insurance 1 * NONE HMSA HMO or PPO HMSA Quest Alohacare Quest Ohana Health Plan Quest United Healthcare UHA HMA HMAA Hawaii Laborer's PSWA Who is the subscriber of the plan? * Patient (for Quest plans) Guardian 1 Guardian 2 No insurance yet Member ID number * Insurance 2 (if applicable) HMSA HMO or PPO HMSA Quest Alohacare Quest Ohana Health Plan Quest United Healthcare UHA HMA HMAA Hawaii Laborer's PSWA None Who is the subscriber of this plan? Patient (for Quest plans) Guardian 1 Guardian 2 Member ID number IMMUNIZATIONS Parents must obtain a copy of your child's immunization records if transferring from another clinic before scheduling an new patient appointment. Please call the clinic to see if your child's immunizations are in our electronic medical database if you do not have a copy. Immunization Policy * I understand that Abinsay Pediatrics clinic accepts only families that have chosen to vaccinate their children or children who cannot receive vaccines due to a medical reason. If your family has chosen to not vaccinate for other reasons, we respect your decision and we kindly ask that you find another clinic. If your child is a newborn, we will be happy to see your child until he/she is 2 months old when the first set of vaccines are given. Yes, I/we are okay with all vaccines No, I/we have chosen to not vaccinate Our child is unable to receive vaccines due to a history of cancer or problem with his/her immune system. PATIENT'S MEDICAL HISTORY Previous doctor or clinic name * Type "NEWBORN" if your baby is a newborn Hospital and city/state/country child was born in * Past Medical History * NONE Asthma Allergies Heart problem Cancer Seizures MIgraines Back problems Kidney problems ADHD Depression / Anxiety Prematurity Jaundice Other Past Surgical History * NONE Tonsils / Adenoids removed Ear tubes Heart surgery Appendix removal Hernia repair Testicle surgery Bone surgery Other Allergies * Type "none" if none Medications currently taking * Type "none" if none Family History * Do any of the following immediate family members have any medical problems? If so, please type them below. - PATIENT'S mom, dad, siblings, grandparents SOCIAL HISTORY Names and ages of siblings * Please include the names and ages of your child's siblings SAFETY: Are there any of the following in the home? * None Smoking Heavy drinking Guns Illegal drug use History of CPS involvement Is there anything else you would like us to know about your child's living situation, exposures at home, or any pertinent social history? Assignment, Release, and Responsibility * CLICK HERE TO READ CONSENTS I have read and consent to the Assignment, Release, and Responsibility Disclosure. Notice of Privacy Practices Acknowledgment * CLICK HERE TO READ CONSENTS I have read and consent to the Notice of Privacy Practices and Acknowledgement. Information of person filling out this form I certify that all the information provided above is true. YOUR NAME * First Name Last Name Relationship to patient * Mother Father Sibling Aunt Uncle Grandmother Grandfather Cousin Foster parent Social worker Today's Date * MM DD YYYY Thank you! Your registration has been received.
