Patient Information form

"Where Compassion, Caring and Dedication Come First"

Patient and Family Information

Patient Last Name:(Required)

First:

Middle:

SEX:(Required)

DOB:(Required)

S.S. no:

Parental Information

Mother Legal Guardian

Last Name:

First:

Middle:

DOB:

S.S. no:

Mailing Address:

Address

City State / Province / Region ZIP / Postal Code

Home Phone:

Cell Phone:

Work Phone:

Email:

Employer:

Occupation:

Marital Status:

Father Legal Guardian

Last Name:

First:

Middle:

DOB:

S.S. no:

Mailing Address:

Address

City State / Province / Region ZIP / Postal Code

Home Phone:

Cell Phone:

Work Phone:

Marital Status:

Has Custody?

Both

Father

Mother

Other

Party Responsible for Payment:

Mother

Father

Guardian

Other

In Case of Emergency

Names of local friend or relative (not living at same address):

Relationship to Patient:

Home Phone no:

Work or Cell Phone no:

List individuals who you can give consent to treat your child:

Relationship to Patient:

Home Phone no:

Work or Cell Phone no:

Authorization Notes

The above information is true to the best of knowledge. I authorize my insurance benefits be paid directly to TLC Pediatrics of Amarillo. I understand that my insurance carrier may pay less than the actual bill of service. I agree to be financially responsible for any balance and for all services rendered. I authorize TLC Pediatrics to release information including diagnosis and, records of treatment or examinations during the period of such care to third party payers and or other health practitioners.

Patient/ Parent/ Guardian:

Date:

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

Patient Information form