New Patient Form HomeNew Patient Form New Patient FormPage 1 of 4Patient Information:NameFirstLastMaleFemaleHome Address*City*State*Zip Code*Date of Birth*AgeCell Phone Number*Email address*Preferred Pharmacy Name*Preferred Pharmacy Phone Number*How did you find about us?*GoogleFacebookYelpObstetrician ReferralFriend ReferralOtherObstetrician NameFriend NamePlease DescribeNextParents Information and Emergency Contact:Father's nameFirstLastDate of Birth*AgeEmployerOcuppationCell Phone*Email address*Mothers NameFirstLastDate of Birth*AgeEmployerOcuppationCell Phone*Email address*Emergency Contact (Other than the parents)FirstLastCell PhoneRelationshipBackNextPrimary Insurance CompanyInsurance Name*Insurance Phone Number*Insured Party Name*Group*ID*Insurance Phone Number*BackNextI give permission for the following people to seek medical care, on my behalf, for the above listed childEmail Address*NameFirstLastAddressCityStateZip CodeCell PhoneRelationshipOnly the following listed people will be permited to obtain information regarding my childNameFirstLastRelationshipNameFirstLastRelationship I consent to treatment as necessary or desired for the above-named patient, including but not limited to any drugs, medicines, procedures, laboratory tests, X-rays, or other studies that may be used by the attending doctor or their qualified designate. I acknowledge full responsibility for the payment of such services at the time of service unless other arrangements have been made. I understand that my insurance carrier is being billed as a courtesy to me, but should they not pay for these charges, I understand that I will assume full financial responsibility. I authorize the release of any medical or other information necessary to process the insurance claim for services provided to my child. I also authorize any payment due from my medical insurance to be paid directly to Little Buddies Pediatrics PA, doing business as Pediatrics of Sugar Land. Signed*Date*BackSend
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