CHILD CARE PEDIATRICS, P.A.

BHARGAV R. TRIVEDI, M.D.

*****************NEW PATIENT REGISTRATION FORM*******************

*REQUIRED FIELD-PLEASE COMPLETE FOR BILLING

PATIENT INFORMATION: (PLEASE USE FULL LEGAL NAME)

*Last Name______________________*First_______________________M.I._________

Nickname____________*Date of Birth_________*Sex__*SS#____________________

*Address____________________________City_______________State____Zip_______

*Primary Phone #________________________Secondary #_______________________

Family Email Address______________________________________________________

PARENT/GUARDIAN INFORMATION: All spaces must be completed for at least one parent/guardian.

Patient’s Mother’s Name__________________________ Date of Birth_____________

(Or Legal Guardian)

Social Security Number___________________ Employer ________________________

Primary Phone# ____________________________ Secondary #____________________

Patient’s Father’s Name __________________________ Date of Birth______________

(Or Legal Guardian)

Social Security Number___________________ Employer ________________________

Primary Phone# ____________________________ Secondary #____________________

*Name(s) and Relationship of person(s) authorized to bring above named patient for medical services to this office and to whom medical information about your child may be disclosed to other than parent/legal guardian and emergency contact:

________________________________________________________________________

EMERGENCY CONTACT INFORMATION: (Other than parent/guardian)

*Emergency Contact Name_______________________ Relationship________________

* Primary Phone Number ______________________ Secondary #__________________

Patient Name __________________________ Date of Birth __________________

*Primary Medical Insurance Company _______________________________________

Name of Insured ____________________ Relationship to Patient __________________

Insured Social Security # ____________________ Insured Date of Birth _____________

Policy ID# ____________________ Group# _________________Effective Date_______

*Secondary Medical Insurance Company _____________________________________

Name of Insured ____________________ Relationship to Patient __________________

Insured Social Security # ____________________ Insured Date of Birth _____________

Policy ID# ____________________ Group# _________________Effective Date_______

************THE REST OF THIS FORM MUST BE COMPLETED***********

Authorization for Medical Treatment of Minors:

I, being the parent or legal guardian of the above named minor, do hereby authorize Dr. Bhargav Trivedi to perform necessary treatments for the above named minor, and during the period of my absence to act on my behalf in authorizing unexpected medical care and hospitalization for the above named minor.

To the extent necessary to determine liability, for payment and to obtain reimbursement, I authorize disclosure of my dependent’s records as needed for billing. I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including Medicaid, private Insurance and other health plans to Dr. Bhargav Trivedi.

These assignments will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by my said insurance. I hereby authorize said assignee to release all information necessary to secure the payment. I understand, that should the insurance information I provided be incorrect and/or a claim is denied I will be responsible for the bill.

I have received and reviewed the NOTICE OF PRIVACY PRACTICES provided by Child Care Pediatrics, P.A., Dr. Bhargav R. Trivedi, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of the document.

______________________________ ______________________________

Name of Patient Signature of Parent/Legal Guardian

_______________________________ ______________________________

Date Relationship to Patient

Child Care Pediatrics, P.A.

Dr. Bhargav R. Trivedi

********************* New Patient History **********************

Patient Name_____________________ DOB____________ Today’s Date___________

Pregnancy and Delivery History:

Born at __________weeks of gestation Birth Weight___________ Height__________

Vaginal Delivery or C-Section (Please circle one)

Any complications during newborn period ___________________________________

Mother’s age at birth of patient____ Abortions__________ Miscarriages__________

Problems during Pregnancy: (circle any that apply)

High Blood Pressure Diabetes Infections STDs Tobacco

Drugs Alcohol GBS

Other (Explain) _____________________________________________________

Past Medical and Surgical History:

Name & Phone # of previous physician__________________________________

Asthma_________________

Hospitalizations_____________________________________________________

Chronic Medical Conditions___________________________________________

Other_____________________________________________________________

Surgeries: ___________________________________________ Ear Tubes: __________

Circumcision: Yes / No

Medications: _____________________________________________________________

Allergies: to food___________________________ to medication____________________

Family History: Please mention the relation of the person having disease:

Asthma_________ Seasonal Allergies___________ Allergy to Medicine________

High Blood Pressure________________ Diabetes__________________________

High Cholesterol_________________ Heart Attack before age 55_____________

ADHD/ADD__________________________ Seizures______________________

Anxiety/Bipolar/Depression___________________________________________

Birth Defects_______________________________________________________

Other_____________________________________________________________

Social History:

Parents Marital Status (circle one):

Married Divorced Separated Single Engaged Widowed

Sibling(s) Name(s) Age(s) ____________________________________________

How many people live in the home _____________________________________

Type of Residence (ex: house, apartment, mobile home) _____________________

Parent’s Occupation_________________________________________________

Smokers (circle one) None Inside Outside only Inside and Outside Pets: Dogs Cats Birds Other: ______________________