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Gracielle and Danny

Registration


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

PATIENT INFORMATION

Name / SS#

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

      INSURED PERSON (IF NOT PATIENT)

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

INSURANCE INFORMATION
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. #

AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFIT

I authorize the release of my medical information necessary to process this claim. I permit a copy of this authorization to be used in the place of the original.

Date
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)  

Upon completion of this form, press the "Submit" button.
To delete or restart, press the "Reset" button. Thank you.

  Please come 5 minutes earlier before your appointment to sign any necessary
  forms. Thank you.

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Web Site Links

   American Academy of Pediatrics (www.aap.org)
  
The official site of the American Academy of Pediatrics.
   Healthy Children (www.healthychildren.org)
  
A new health information website designed by the American Academy of Pediatrics
        for parents.
   Kids Health (www.kidshealth.com)
  
A website containing doctor-approved information about children's health.
   Teens' Health (www.kidshealth.com/teen)
  
A great health information website for teens.
   Center for Young Womenís Health (www.youngwomenshealth.org)
  
From the Childrenís Hospital of Boston, this website is full of information on young
        womenís health.
   CDC Travel Website (www.cdc.gov/travel)
  
Great resource for traveling abroad. Website containing recommended vaccines for
        specific areas, information for traveling with children and outbreak alerts.
   CDC Vaccine Site (www.cdc.gov/vaccines)
  
National Immunization Program (NIP) through the CDC provides vaccine information
        for healthcare professionals and parents.
   Vaccine Information from CHOP (www.vaccine.chop.edu) 
  
A vaccine education center for the Childrenís Hospital of Philadelphia.
   Institute for Vaccine Safety (www.vaccinesafety.edu)
  
A
website run by Johns Hopkins University that provides independent information
        regarding vaccines and vaccine safety.
  CHADD (www.chadd.org)
 
A non-profit organization that helps people affected by ADHD. Website includes links
        to support groups and conferences.
  CDCís Information for ADHD (www.cdc.gov/ncbddd/adhd)
  Consumer Product Safety Commission (www.cpsc.gov)
 
An Up-to-date information about product recalls.
  Safety Issues from A-Z   
 
(
www.nlm.nih.gov/medlineplus/childsafety.html#cat22)
        
A website with topics on various safety issues.
  Safekids (www.safekids.org)
 
An organization whose mission is to prevent accidental childhood injury.
  National Highway Traffic Safety Commission (www.nhtsa.gov/Safety/CPS)
 
Safety guidelines for driving with children.
  Internet Safety Education for Kids and Teens (www.netsmartz.org/Parents)
  
A
website teaching internet safety to kids and teens.
  National Eating Disorders Association (www.eatingdisorderscoalition.org)
  Sleep Problems (www.med.umich.edu/yourchild/topics/sleep.htm)
 
Information on sleep that was rated highly by the Child and Family Web Guide
  Children and Sleep
  (www.sleepfoundation.org/article/sleep-topics/children-and-sleep)

        
Articles on children and sleep.



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