graphic: kids

Is Your Child Sick?TM

Emergencies

Medical Emergency:
Poison Control:

Office After Hours:
Call 911
(800) 222-1222

(808) 524-2575

Patient Registration


LIST ALL CHILDREN



Sex:




Sex:





Sex:





And (for appointment reminders and contacting)

PARENT (OR LEGAL GUARDIAN) INFORMATION

(last, first middle)













(if different from above)







BILLING ADDRESS (IF DIFFERENT FROM ABOVE)

(name or industry)





EMERGENCY CONTACT INFORMATION







INSURANCE INFORMATION

Is this patient covered by insurance?:

1. PRIMARY INSURANCE

Primary Insurance:








Patient’s relationship to subscriber:

Sex:


2. SECONDARY INSURANCE

Secondary Insurance:








Patient’s relationship to subscriber:

Sex:


I certify that the above information is accurate and current to the best of my knowledge. By providing my cell phone number and/or email address, I consent to Reis Pediatrics contacting me regarding my child’s medical care via cell phone, text or email.

Credit Card Payment Authorization:








By signing below, you are agreeing to and understand the above financial agreement and that you understand, as the parent and/or guarantor of the minor child described above as being the patient, that you are responsible for any charges incurred and agree to pay them as required within 30 days of receiving your billing statement.