Child New Patient Information Form

Child Registration Form - Medical

Patient Information


 




Parent / Guardian Information

Parents' Marital Status


Emergency Contact Information

Person(s) OK to release appointment or medically related information to concerning child:

Insurance Information




Medical History

Is your child currently being treated by a physician?
Does your child have any allergies/sensitivities to medications or latex?
Is your child currently taking any prescription or over-the-counter medications?
Has puberty and/or menstruation begun?
Has your child ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Has your child had any serious illnesses or operations? If yes, describe:
Has your child ever had a blood transfusion?
Check if your child has or has ever had any of the following:

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.

I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.



Security Measure

Springfield Nephrology Associates

  • Springfield Location - 1911 S. National Ave., Springfield, MO 65804 Phone: 417-886-5000 417-886-5000
  • Bolivar Location - 1165 N. Butterfield Rd., Suite B1, Bolivar, MO 65613 Phone: 417-886-5000
  • Lebanon Location - 341 Hospital Dr., Suite 300, Lebanon, MO 65536 Phone:
  • West Plains Location - 803 W. Broadway St., West Plains, MO 65775 Phone:
  • Mountain Grove Location - 1206 N. Main Ave., Suite B, Mountain Grove, MO 65711 Phone:
  • Aurora Location - 500 Porter Ave., Aurora, MO 65605 Phone: 417-886-5000

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