Step 1 of 3 - Patient Registration33%Patient RegistrationChild 1Name* First Middle Last Sex* M FDate of Birth* Month Day YearSchoolMailing 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?* Yes NoDate of Birth* Month Day YearSocial Security NumberWork PhoneCell Phone*Home Email Work Email Employer*OccupationDad/GuardianNameRelation to PatientLives with patient? Yes NoDate of Birth Month Day YearSocial Security NumberWork PhoneCell PhoneHome Email Work Email EmployerOccupationAre parents divorced or separated? Yes NoIf 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? Yes NoPlease explain and provide a copy of any legal paperwork that supports this restrictionFileAccepted file types: pdf, doc, docx, Max. file size: 10 MB..pdf, .doc,. docx allowedEmergency ContactsOther than parentsName*Relationship*Phone*NameRelationshipPhone HIPAA Compliant Authorization for Release of Health InformationName*I authorize West Coast Pediatrics including its employees toAuthorize obtain exchange usegeneral medical psychiatric/psychological, legal, alcohol and/or drug abuse information pertaining toPatient Name*Date of Birth* Month Day YearPurpose of Release Treatment Planning Reimbursement Psychological Evaluation Consultation Legal OtherFromName 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 Released All 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 InformationI 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* Month Day Year Medical Treatment Consent FormChild Name*Date of Birth* Month Day YearParent 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 your voicemail, may we leave a message? Yes NoI 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* Month Day YearCAPTCHACommentsThis field is for validation purposes and should be left unchanged.