[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=\u201d4.22.1\u2033 _module_preset=\u201ddefault\u201d width=\u201d90%\u201d max_width=\u201d1500px\u201d hover_enabled=\u201d0\u2033 global_colors_info=\u201d{}\u201d sticky_enabled=\u201d0\u2033][et_pb_column type=\u201d4_4\u2033 _builder_version=\u201d4.22.1\u2033 _module_preset=\u201ddefault\u201d global_colors_info=\u201d{}\u201d][et_pb_code _builder_version=\u201d4.22.1\u2033 _module_preset=\u201ddefault\u201d width=\u201d100%\u201d hover_enabled=\u201d0\u2033 locked=\u201doff\u201d global_colors_info=\u201d{}\u201d module_id=\u201dfor-57\u2033 sticky_enabled=\u201d0\u2033]

<\/div>

Patient's First Name<\/label><\/div><\/div>

Last Name<\/label><\/div><\/div>

Middle Intials<\/label><\/div><\/div><\/div>

Date of Birth<\/label><\/div><\/div>

Sex<\/label><\/div><\/div><\/div>

Street Address<\/label><\/div><\/div><\/div>

City<\/label><\/div><\/div>

State\/Province<\/label><\/div><\/div><\/div>

ZIP \/ Postal Code<\/label><\/div><\/div><\/div><\/div><\/div>

Mother's Name<\/label><\/div><\/div>

Date of Birth<\/label><\/div><\/div><\/div>

Street Address<\/label><\/div><\/div><\/div>

City<\/label><\/div><\/div>

State\/Province<\/label><\/div><\/div><\/div>

ZIP \/ Postal Code<\/label><\/div><\/div><\/div><\/div><\/div>

Home Phone<\/label><\/div><\/div>

Cell Phone<\/label><\/div><\/div>

Work Phone<\/label><\/div><\/div><\/div>

Employee\/Occupation<\/label><\/div><\/div>

SSN<\/label><\/div><\/div><\/div>

Father's Name<\/label><\/div><\/div>

Date of Birth<\/label><\/div><\/div><\/div>

Street Address<\/label><\/div><\/div><\/div>

City<\/label><\/div><\/div>

State\/Province<\/label><\/div><\/div><\/div>

ZIP \/ Postal Code<\/label><\/div><\/div><\/div><\/div><\/div>

Home Phone<\/label><\/div><\/div>

Cell Phone<\/label><\/div><\/div>

Work Phone<\/label><\/div><\/div><\/div>

Employee\/Occupation<\/label><\/div><\/div><\/div>

SSN<\/label><\/div><\/div><\/div>

Emergency Contact<\/label><\/div><\/div>

Phone No.<\/label><\/div><\/div><\/div>

Please bring a copy of your child\u2019s insurance card to all visits.<\/label>Please List all insurances Patient is covered under.In order for us to file your insurance correctly, please complete the following:<\/div><\/div><\/div>

Primary Insurance Name<\/label><\/div><\/div><\/div>

Type of Product<\/span><\/span>Medicaid<\/span><\/label><\/span>HMO<\/span><\/label><\/span>POS<\/span><\/label><\/span>PPO<\/span><\/label><\/div><\/div><\/div>

Policy ID<\/label><\/div><\/div>

Group#<\/label><\/div><\/div>

Phone#<\/label><\/div><\/div><\/div>

Insured Name<\/label><\/div><\/div>

Date of Birth<\/label><\/div><\/div>

SS#<\/label><\/div><\/div><\/div>

Does the patient have Medicaid and Private Insurance?<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div><\/div>

Patient History<\/h2><\/div><\/div><\/div>
Name<\/label><\/div><\/div>
Date of Birth<\/label><\/div><\/div>
Sex<\/label><\/div><\/div>
Location<\/label><\/div><\/div><\/div>
Type of delivery<\/span><\/span>Vaginal<\/span><\/label><\/span>C-Section<\/span><\/label><\/span>Forceps<\/span><\/label><\/div><\/div>
Mother's Age<\/label><\/div><\/div>
Born at<\/label><\/div><\/div>
Weeks Length<\/label><\/div><\/div><\/div>
Birth Weight<\/label><\/div><\/div><\/div>
ILLNESS HISTORY(Y\/N)<\/h2><\/div><\/div><\/div>
EYE PROBLEMS<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div>
ASTHMA<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div>
CHICKEN POX<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div><\/div>
PNEUMONIA<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div>
EAR INFECTIONS<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div>
HEART MURMUR<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div><\/div>
ECZEMA<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div>
HEART PROBLEMS<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div>
ANEMIC<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div><\/div>
SEIZURES<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div>
CONSTIPTION<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div>
URINARY TRACT INFECTION<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div><\/div>
TEETH PROBLEMS<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div>
ALLERGIES<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div>
NERVOUS SYSTEM<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div><\/div>
HOSPITALIZATIONS<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div>
OPERATIONS\/SURGERIES<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div><\/div>
Family Medical History<\/h2><\/div><\/div><\/div>
Aids<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div>
Allergies\/Eczema<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div>
Anemia\/Blood Disorder<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div><\/div>
Asthma\/Resp Problems<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div>
Cancer<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div>
Cholesterol<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div><\/div>
Depression<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div>
Diabetes<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div>
Drug\/Alcohol Problems<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div><\/div>
Epilepsy<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div>
Heart attack before 50<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div>
Heart disease<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div><\/div>
High blood pressure<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div>
Migraine<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div>
Sudden Infant Death<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div><\/div>
Tuberculosis<\/span><\/span>Yes<\/span><\/label><\/span>No<\/span><\/label><\/div><\/div><\/div>
ALLERGIES (Please List)<\/h2><\/div><\/div><\/div>
Medications<\/label><\/div><\/div>
Foods<\/label><\/div><\/div>
Other<\/label><\/div><\/div><\/div>
FAMILY PROFILE<\/h2><\/div><\/div><\/div>
Father's Name<\/label><\/div><\/div>
Date of Birth<\/label><\/div><\/div>
Occupation<\/label><\/div><\/div><\/div>
Mother's Name<\/label><\/div><\/div>
Date of Birth<\/label><\/div><\/div>
Occupations<\/label><\/div><\/div><\/div>
Sibling Name<\/label><\/div><\/div>
Date of Birth<\/label><\/div><\/div>
Sex<\/label><\/div><\/div>
Date of Birth<\/label><\/div><\/div>
Sex<\/label><\/div><\/div>
Date of Birth<\/label><\/div><\/div>
Sex<\/label><\/div><\/div>
Date of Birth<\/label><\/div><\/div>
Sex<\/label><\/div><\/div><\/div>
Authorization to Treat<\/h2><\/div><\/div><\/div>
parent\/guardian<\/label><\/div><\/div>
Date<\/label>
<\/span><\/div><\/div><\/div><\/div>
HTML<\/label>Please list the people whose permission you grant to authorize treatment and seek information (when you not available to give consent) pertaining to the care of your child.<\/div><\/div><\/div>
Name<\/label><\/div><\/div>
Phone<\/label><\/div><\/div>
Relationship to child<\/label><\/div><\/div><\/div>
Name<\/label><\/div><\/div>
Phone<\/label><\/div><\/div>
Relationship to Child<\/label><\/div><\/div><\/div>
Name<\/label><\/div><\/div>
Phone<\/label><\/div><\/div>
Relationship to Child<\/label><\/div><\/div><\/div>
WRITTEN ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES<\/label>
I acknowledge that Texas Family Pediatric Group provided me with the Notice of Privacy Practices. I give permission for my protected health information to be used by Texas Family Pediatric Group and disclosed to others for the purposes of treatment, obtaining payment, or supporting the day to day health care operations of the practice. I understand that I may request restrictions on the use or disclosure of my protected health information and that if Texas Family Pediatric Group agrees to this request, the restriction will be binding on the practice. I further understand that I may revoke, in writing this consent to use and disclose protected health information.<\/p><\/div><\/div><\/div>
Patient's Name<\/label><\/div><\/div>
Patient\u2019s Representative<\/label><\/div><\/div><\/div>
Relationship to parents<\/label><\/div><\/div>
Date<\/label>
<\/span><\/div><\/div><\/div><\/div>
Guarantor\u2019s Statement of Responsibility<\/label>
1. That the responsible party will make immediate payment for services rendered; If Texas Family Pediatric Group is contracted with your insurance company, payment is due immediately on co-pays, non-covered services and co-insurance.<\/p>\n
2. That it is the responsibility of the policy holder to familiarize themselves with their insurance policy, and its benefits and limitations.<\/p>\n
3. That I authorize payment of medical benefits to Texas Family Pediatric Group for services rendered. I also understand that ultimately I am financially responsible to Texas Family Pediatric Group for all charges whether or not covered by my insurance carrier.<\/p><\/div><\/div><\/div>
Date<\/label>
<\/span><\/div><\/div><\/div><\/div>
Print Name of Responsible Party<\/label><\/div><\/div>
Relationship to Patient<\/label><\/div><\/div><\/div>

Texas Family Pediatric Group P.A.<\/h2>\n