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 childNameFirstLastAddressCityStateZip 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*BackSendThis field should be left blank
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