UPDOX - PATIENT PORTAL

Child Information

Name * DOB * SSN # * M/F * Mailing Address * Home Phone # * E-Mail Address * Preferred Pharmacy * Child's School ( If Applicable)

Parent Information (Mother, Father, or Legal Guardian) - REQUIRED

Parent #1 Name * Employer Home Address * Home Phone # * Cell Phone # * DOB * SSN * Parent #2 Name * Employer Home Address * Home phone Cell Phone * DOB * SSN * Emergancy contact Other than Parent's *

Insurance Information

Name of Insurance Company * Insurance Company Address Policy Holder Name * Policy Holder Address * Policy Holder Phone # * Policy Holder DOB * Policy Holder Employer Policy # * Group # *

This is a direct assignment of my rights and benefits under this policy, I agree to pay charges not paid by insurance. A photocopy of this agreement shall be considered as effective and valid as the original. I also authorize the release of any information pertinent to my case to any insurance company , adjuster, or attorney involved in this case. I have received a copy of HIPPA (Health Insurance Portability and Privacy Act)and agree to the policy.

Name and DOB of Guardian completing form * Electronic Signature of Guarantor/Guardian * Date *

Parent or Guardian preference regarding communication of health information. I herby give permission for the following people to obtain medical care for my child.

Name and Relationship of all persons Please put initials here if you wish to NOT give permission for additional family members, relatives, or close personal friends to obtain care for your child in your absence or have access to any information regarding your childs medical history.

Family Profile

Number of persons living in the house. (Mom, dad, brothers sisters, guardians, grandparents) Siblingsa name and age.

Past Medical History

General Health Allergies (Foods, Pollen, animals) Allergies to any medications Birth Weight/ Premature or Full Term Any newborn problems All Surgeries All recurring illnesses List serious illnesses/ accident that requires overnight hospitalization All Medications Being Taken Any sickle cell or sickle trails? Any transfusions? Any Anemia? Other significant medical/ emotional problems

Immunizations

Do you have child's immunization records? Immunizations up to date? Temperature more then 102, a screaming fit, convulsions after immunization? Ever had a positive TB skin test?

Family History

Do any family members have a history of?

Alcoholism/substance abuse allergy/asthma Birth defects Blood Problems Cancer Diabetes Heart Problems High Blood Pressure High Cholesterol Mental/ emotional problems Migranes Seizures/epilepsy Sickle cell problems Stroke Tuberculosis/Aids Other: Name and DOB of Guardian completing form * Date *