Patient Name (Last Name, First Name, Middle Initial): Gender: F  Age:   Birthdate:  

Mailing Address:  City:  State Zip Code: 
 

Please provide at least two contact phone numbers and indicate which is the best contact number by checking the corresponding box below.
(It is very important that we have multiple phone numbers in order for our medical staff to contact you quickly with lab results & general return phone calls)

Home Phone:  Mobile Phone:  Work Phone:   
Emergency Contact:  Relationship to Patient:  Phone: 

 

Parent #1


 
Name:  Gender: F Email:   Date of Birth: 
Mailing Address (if different than child):  Preferred Phone #: 
Home Cell Work
Employer: 
 

Parent #2


Name:  Gender:  Email:  Date of Birth: 
Mailing Address (if different than child): Preferred Phone #: 
Home Cell Work
Employer: 

Responsible Party (This person must sign financial policy)


 
Name:  Relationship to Patient:  Mailing Address (if different than child): 
Preferred Phone #: 
Home Cell Work
Email:  Employer: 
Occupation: 
Social Security #:   Driver License #:  Date of Birth: 

 

Siblings Who Are Also Seen at Cornerstone Pediatrics (please list all siblings who are also seen by our physicians): 


Name:  DOB:  Gender: 
Name:  DOB:  Gender: 
Name:  DOB:  Gender: 
Name:  DOB:  Gender: 

Insurance Information  (Primary Coverage): 


Insurance Company Name:  Policy / ID #:  Group #: 
Effective Date:  Primary Insured's Name:  Relation to Patient: 
Primary Insured’s Place of Employment:  Primary Insured’s Date of Birth:  Phone Number: 

Do you have additional medical insurance? (if so, please list below) Yes No

Insurance Information (Secondary Coverage): 


 
Insurance Company Name:  Policy / ID #:  Group #: 
Effective Date:  Secondary Insured’s Name:  Relation to Patient: 
Secondary Insured’s Place of Employment:  Secondary Insured’s Date of Birth:  Phone Number: 

How Did You Hear About Us? 


Please check all that apply:
    
Yellow Pages Online Yellow Pages Pharmacy Bag New Neighbor Welcome Service or Other New Resident Welcome Service 
Friend:  Internet Search:  School: 

Assignment & Release: 


 
I give permission for Physicians of Cornerstone Pediatric & Adolescent Medicine, or persons designated by them, to interview, examine and perform necessary laboratory procedures and to provide appropriate treatment to the above named minor. I further give my permission for evaluation and treatment whether the child is accompanied by a parent/legal guardian, other family member, unrelated third party or is unaccompanied.
  
Signed: Click and draw with your mouse or write with your touch screen. Relationship to Patient: 
Print Name:  Today's Date: 


I, the undersigned, assign directly to Cornerstone Pediatric & Adolescent Medicine, PA all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the use of this signature on all insurance submissions.

I further authorize Cornerstone Pediatric & Adolescent Medicine, PA to forward any information necessary, including, but not limited to medical records, to said insurance company for payment of my insurance claims as well as to other personnel to whom physicians of Cornerstone Pediatric & Adolescent Medicine have referred my child for treatment and to the admitting hospital should my child be admitted for treatment.

PLEASE NOTE: Whoever accompanies the child to each visit is expected to pay the charges due for the service rendered that day, including copayments, coinsurance, deductibles, etc. Divorce has no bearing on the responsibility for medical care as it affects third parties. 


 
Signed: Click and draw with your mouse or write with your touch screen. Relationship:  Date: