Registration and Web Site Links

Gracielle and Danny


Please type all the required information in the spaces provided below:


Name / SS#

Street Address
City, State, Zip Code
Date of Birth
Home Tel. #
Referred By
Father's Name 
Mother's Name 


Name / SS# 
Street Address (if different)
City, State, Zip Code
Date of Birth / Tel. #
Employer Name

Employer Street Address

City, State, Zip Code

Tel. # / Occupation

Primary Insurance
Street Address 
City, State, Zip Code
Tel. #
ID #
Group #
Secondary Insurance
Name / SS#
Street Address 
City, State, Zip Code
ID #
Group #
Date of Birth / Tel. #


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Patient, Parent or Guardian
Signature (In Person)  

I, hereby, authorize Dr._________________ to apply for benefits on my behalf for covered services rendered by him. I request that payment from my insurance company be made directly to Dr._______ (or to the party who accepts assignment). I agree to pay for all charges not covered by a third party payer.
I certify that the information I have reported with regard to my insurance coverage is correct.
I permit a copy of this authorization to be used in place of the original. This authorization may be revoked by either me or my insurance company at any time in writing.

Date / Time
Patient, Parent or Guardian
Signature (In Person)  

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  Please come 5 minutes earlier before your appointment to sign any necessary
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Web Site Links

   American Academy of Pediatrics (
The official site of the American Academy of Pediatrics.
   Healthy Children (
A new health information website designed by the American Academy of Pediatrics
        for parents.
   Kids Health (
A website containing doctor-approved information about children's health.
   Teens' Health (
A great health information website for teens.
   Center for Young Womenís Health (
From the Childrenís Hospital of Boston, this website is full of information on young
        womenís health.
   CDC Travel Website (
Great resource for traveling abroad. Website containing recommended vaccines for
        specific areas, information for traveling with children and outbreak alerts.
   CDC Vaccine Site (
National Immunization Program (NIP) through the CDC provides vaccine information
        for healthcare professionals and parents.
   Vaccine Information from CHOP ( 
A vaccine education center for the Childrenís Hospital of Philadelphia.
   Institute for Vaccine Safety (
website run by Johns Hopkins University that provides independent information
        regarding vaccines and vaccine safety.
A non-profit organization that helps people affected by ADHD. Website includes links
        to support groups and conferences.
  CDCís Information for ADHD (
  Consumer Product Safety Commission (
An Up-to-date information about product recalls.
  Safety Issues from A-Z   
A website with topics on various safety issues.
  Safekids (
An organization whose mission is to prevent accidental childhood injury.
  National Highway Traffic Safety Commission (
Safety guidelines for driving with children.
  Internet Safety Education for Kids and Teens (
website teaching internet safety to kids and teens.
  National Eating Disorders Association (
  Sleep Problems (
Information on sleep that was rated highly by the Child and Family Web Guide
  Children and Sleep

Articles on children and sleep.

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About Dr. DeLorenzo  

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