Step 1 of 3 - Patient Registration 33% Patient RegistrationChild 1Name* First Middle Last Sex*MFDate of Birth* MM DD YYYY SchoolMailing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Who lives at this household?Insurance: PLEASE PRESENT CARD TO FRONT DESKMom/GuardianName*Relation to Patient*Lives with patient?*YesNoDate of Birth* MM DD YYYY Social Security NumberWork PhoneCell Phone*Home Email Work Email Employer*OccupationDad/GuardianNameRelation to PatientLives with patient?YesNoDate of Birth MM DD YYYY Social Security NumberWork PhoneCell PhoneHome Email Work Email EmployerOccupationAre parents divorced or separated?YesNoIf parents are divorced or separated, who has custody?Are there any legal restrictions that would restrict the non-custodial parent from consenting to medical treatment for the child or from obtaining information about the child's medical treatment?YesNoPlease explain and provide a copy of any legal paperwork that supports this restrictionFileAccepted file types: pdf, doc, docx..pdf, .doc,. docx allowedEmergency Contacts Other than parentsName*Relationship*Phone*NameRelationshipPhone HIPAA Compliant Authorization for Release of Health InformationName*I authorize West Coast Pediatrics including its employees toAuthorize release obtain exchange use general medical psychiatric/psychological, legal, alcohol and/or drug abuse information pertaining toPatient Name*Date of Birth* MM DD YYYY Purpose of Release Treatment Planning Reimbursement Psychological Evaluation Consultation Legal Other FromName and address of the person or entity to an/or from whom disclosure is being made or who will be using the informationToInformation to be ReleasedAll Medical Records (Including information related to HIV/sexually transmitted disease, sexual activity/pregnancy or contraception, psychiatrist/mental health disorders, drug or alcohol use, physical/sexual abuse or medical neglect.)All Medical Records with the Exception of the Following InformationAll Medical Records Exception Information I understand that authorizing the disclosure of this health information is voluntary and you have my consent to release medical records for all dates including all diagnostic tests for any type and reports, history, hospitalization, diagnosis, prognosis, treatment, medication and pharmacy records, correspondence, consults, statement of charges or expenses. Any and all reports of any type or character. I understand that the information authorized for release may include records which may indicate the presence of a communicable or non-communicable disease. This authorization will expire one year from the date signed. A copy or facsimile of this authorization shall be counted true and valid as original.Signature of Patient or Legal Representative*Date* MM DD YYYY Medical Treatment Consent FormChild Name*Date of Birth* MM DD YYYY Parent Name*Relationship to Patient*I give permission for the medical staff to contact me at the following numbers regarding patient care, test results, appointments, prescription and billing questions.Home Phone NumberWork Phone NumberCell Phone NumberIf we get you voicemail, may we leave a message?YesNoI hereby authorize West Coast Pediatrics to treat my child and discuss appointments and test results with these designated persons:Persons ListNameRelationship to Patient Signature*Date* MM DD YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.