Patient Name   SSN
Address City State        ZIP
Mom's Name 
Mom's Occupation 
Dad's Name  
Dad's Occupation
Legal Guardian

Phone numbers:
Home   Work   Cellular
Fax      E-mail

In Case of Emergency, Contact...
Name     Phone
Relationship

I Authorize...  (leave blank if not applicable)
Name
Relation to patient
To accompany patient for:
Routine health maintenance    Sick visits
Shots                                   Blood work

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Insurance
Person responsible for this account
Relationship to patient
SSN   
Insurance company
Group Number

Additional Insurance  Yes    No
Subscriber Name
Relationship to patient
Insurance company
Group Number

Assignment and Release
I (we) the undersigned certify that I (or my dependent) have insurance coverage with and assign directly to Pediatric Consultants of Hampton Roads all insurance benefits.  I understand that I am financially responsible for all charges whether or not paid by insurance.  I authorize Pediatric Consultants of Hampton Roads to release all information necessary to secure the payment of benefits. 

Responsible party signature: ________________________
                                           ________________________
                                  Date: _______________