Menu

Child New Patient Information

_2017 Child Registration Form - Medical

Patient Information

Gender:
Phone Type
OK to leave message?

Parent / Guardian Information

Parent 1

Marital Status:
Relation to Child:
Phone Type:
Phone Type:

Parent 2

Marital Status
Relation to Child:
Phone Type:
Phone Type:

Emergency Contact Information

Insurance Information

Primary Insurance

Secondary Insurance

Medical History

Is your child currently being treated by a physician?
Is your child currently taking any prescription or over-the-counter medications?
Has puberty and/or menstruation begun?
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

New Mexico Eye Clinic

  • New Mexico Eye Clinic - 2300 E. 30th St. Suite 105, Farmington, NM 87401 Phone: 505-327-0406 Fax: 505-326-4691

2018 © All Rights Reserved | Website Design By: West | Login