Fillable PATIENT INFORMATION FORM

Fill Online, Printable, Fillable, Blank PATIENT INFORMATION FORM Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

PATIENT INFORMATION FORM

On average this form takes 30 minutes to complete

The PATIENT INFORMATION FORM form is 3 pages long and contains:

  • 0 signatures
  • 16 check-boxes
  • 111 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
411 Lantern Bend Dr, Ste 235 Houston, TX 77090
P:281-979-2112, F:281-884-3558
PATIENT INFORMATION FORM
Today’s date:
Who referred you to our practice?
Child’s Legal Name: D.O.B.: M / F
Address: Race: _________________________
City, Zip Code Grade/School: _________________________
Insurance Company Name: #1 Primary or Secondary
Policy number/Member ID: Group #: formation
Insurance Company Name: #2 Primary or Secondary
Policy number/Member ID: Group #: formation
Mother’s Name: D.O.B.:
Address (if different from Patient): SS#: / /
City, Zip:
Phone Numbers: Home: Cell: Work:
Employer: Occupation:
Email:
Father’s Name: D.O.B.:
Address (if different from Patient): SS#: / /
Same as Patient
Phone Numbers: Home: Cell: Work:
Employer: Occupation:
Email:
Sibling’s Name: D.O.B.:
Sibling’s Name: D.O.B.:
Sibling’s Name: D.O.B.:
Sibling’s Name: D.O.B.:
Sibling’s Name: D.O.B.:
Sibling’s Name: D.O.B.:
Emergency Contact: _______________________ Relation to Patient: ______________ Phone #: ________________
Pharmacy: _______________________________ Phone #:________________________
Child’s Information
Mother’s Information
Father’s Information
Siblings’ Information
411 Lantern Bend Dr, Ste 235 Houston, TX 77090
P:281-979-2112, F:281-884-3558
PATIENT HISTORY FORM
Patient’s Name: DOB:
Was this child O Full Term O Preterm O Adopted (at what age?) How many weeks at delivery?
Type of delivery: O Vaginal O C-section Reason for C-section NICU stay: O Yes O No
Birth Weight: Length:
Did he/she have any problems in the newborn period?
Please check any illnesses your child has had
Anemia
Asthma
Heart Murmur
Pneumonia _______ (date)
RSV/Bronchiolitis/Bronchitis
Recurrent throat infections
Allergies
Seizures
Eczema
Reflux (GERD)
UTI ADD ADHD
Other:
Chicken Pox _______ (date)
Recurrent ear infections
Sugeries/hospitalizations & dates:
Allergies:
List all medications:
Please indicate what family member has the following medical problems: Mother(M), Father(F), Brother(B), Sister(S), maternal
grandmother(MGM), maternal grandfather(MGF), maternal aunt(MA), maternal uncle(MU), paternal grandmother, (PGM), paternal
grandfather(PGF ), paternal aunt(PA), paternal uncle(PU)
Anemia Allergies Asthma Bleeding disorder
Bipolar Cancer Crohn’s disease Diabetes
Eczema Emotional problems Epilepsy Heart Attack
High blood pressure High cholesterol Kidney Disease Lazy Eye
Lupus Migraines Pneumonia Renal disease
Sickle Cell Trait/Diease Stroke Thyroid disease Tuberculosis
Ulcerative Colitis Unexplained/Sudden Death HIV/AIDS Urinary Reflux
Other conditions not listed
Is there anything more you would like us to know about your child?
I voluntarily authorize and consent to the child listed below to receive medical care, treatment, vaccines, and diagnostic tests that are
deemed necessary by the clinicians and healthcare personnel at Premier Pediatrics of Houston, PLLC while he/she is a patient or until
I withdraw my consent. By signing below, I verify that I have the legal right to consent for the patient listed below and that I have read
(or they were read to me in a language that I understand) and I agree to follow the policies set forth in the No Show Policy,
Immunization Policy, Financial Policy, and Privacy Practices.
Patient Name: _______________________________________________________Patient’s DOB: _________________________
Name of Parent/Guardian: ______________________________________________
Signature of Parent/Guardian: ___________________________________________ Date: ________________________________
Birth History
Past Medical History
Family History
411 Lantern Bend Dr. Ste 235 Houston, TX 77090
P: 281-979-2112, F:281-884-3558
No Show Policy
A No Show occurs if a patient does not show for a scheduled appointment within 30 minutes OR
a parent/guardian has not called to cancel a scheduled appointment at least 4 hours prior to the
scheduled appointment. All insured and non-insured patients will be charged a $25.00 No Show
fee on the second and third missed appointment and dismissal from the practice may result after
any subsequent No Shows within a 1 year time frame. The purpose of this policy is not to punish,
but rather to improve scheduling opportunities to allow for adequate use of available patient
appointment slots and enhanced use of patient, staff and provider time.
No Show #1: The parent/guardian for the patient will be notified of the missed
appointment and advised that subsequent missed appointment, without notifying the
practice within the cancellation time frame, will result in a $25.00 fee.
No-Show #2: The parent/guardian of the patient will be notified by phone and receive a
letter informing them of the two No Show visits and the $25.00 charge that must be paid
prior to being seen for another appointment.
No-Show #3: The parent/guardian of the patient will receive a phone call and letter
informing them that their account has been flagged for habitual No Shows and that
another no-show may result in dismissal from the practice. They will again be charged a
$25.00 fee that must be paid prior to being seen for another appointment.
______________________________________________________________________________
Patients who No Show as a Double/Triple/Quad Appointment (2, 3, or 4 patients being
seen at the same time) will be charged a No Show fee for each child who misses the
appointment and may be restricted from scheduling multiples appointments in the future.
Patients who No Show as a Double/Triple/Quad Well Child Visit appointments will be
charged a $25 No Show fee for each child who misses their appointment and NO future
multiple Well Child Visit appointments will be scheduled in the future.
The undersigned has read and agrees to the above No Show Policy of Premier Pediatrics of
Houston.
_____________________________ ________________________________
Print Name of Parent Signature of Parent
___________________________________________ ________________________________________________
Patient Name Date
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

PATIENT INFORMATION FORM

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 18 January 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document