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Medical History & Insurance Information Form

Medical History & Insurance Information Form

3501 Soncy Road, Suite 102
Amarillo, Texas 79119
Tel: 806-353-7900
Fax 806-353-8321
tlcofamarillo.com
Where Compassion, Caring and Dedication Come First

"Where Compassion, Caring and Dedication Come First"

Insurance Information

Please give your insurance card to the receptionist.

Person Responsible for bill:

Address (if different)

Home Phone No

Employer

Employer Address

Employer Phone No

Name of Primary Insurance:

Group no:

Subscriber’s S.S. no.:

Subscriber Name:

Birth Date:

MM slash DD slash YYYY

Name of Secondary Insurance:

Group no:

Policy no:

Subscriber’s S.S. no.:

Subscriber Name:

Birth Date:

Patient’s Relationship to Subscriber:

Child

Other

Family History

Family Member

Name

Age

Health Problem

Any significant history of disease in relatives?

Any significant relatives with sudden death prior to age 50?

Yes

No

If yes, who?

Are natural parents living together:

Yes

No

Third Choice

If no, please explain

Prenatal, Growth and Development History

Any Child Deaths:

Patient’s Birth Weight :

Was Patient full term :

If not How many weeks

Delivery :

Vaginal

C-Section

Health History

Has your child ever had: (Please check appropriate answer)

Chicken Pox

Yes

No

Diabetes

Yes

No

Rheumatic Fever

Yes

No

Eczema/Skin Problems

Yes

No

Pneumonia

Yes

No

Convulsion Epilepsy

Yes

No

High Blood Pressure

Yes

No

Croup

Yes

No

Emotional Disorder

Yes

No

Asthma/Wheezing

Yes

No

TB/ Lung Disease

Yes

No

Cancer

Yes

No

Frequent sore throats

Yes

No

High Cholestero

Yes

No

Allergies

Yes

No

Frequent Cold

Yes

No

HIV/AIDS

Yes

No

Hepatitis

Yes

No

Kidney Bladder Problems

Yes

No

Handicaps/ Disabilities

Yes

No

Congenital Heart Defect

Yes

No

Frequent Ear Infection

Yes

No

Please explain any medical problem(s) your child may have:

Mumps, Measles

Yes

No

Hemophilia

Yes

No

Heart Murmur

Yes

No

Note : you can fill out and save the form as well by downloading after submitting

Welcome to TLC Pediatrics of Amarillo! We are glad you have chosen us as your child’s pediatrician and strive to give your children the best in medical care.

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+(806) 353-7900

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Patient Announcement

We’re excited to share some wonderful news! Our temporary office is now located at:

8900 E. Village Square, Amarillo, 79119 (click to open location in map)

And even more exciting — starting September 1, Dr. Anders J. Leverton, M.D., FAAP will be joining our practice! Dr. Leverton is well known for his kindness, dedication, and commitment to providing the very best care for his patients. We’re truly thrilled to welcome him to our team.

With Dr. Leverton, MD, FAAP, joining out team, we are excited to announce that we are accepting newborn patients. Our entire team is dedicated to delivering compassionate, high-quality care, and we look forward to caring for you and your family while continuing to serve our community with excellence.

Please continue to check our website for updates.