"Child and Adolescent Patient Demographic Form - Righteous Oaks"

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Patient Demographic Form
CHILD AND ADOLESCENT
Please PRINT
DATE: ____________
PATIENT INFORMATION
LAST NAME
FIRST NAME
MI
NICKNAME
DATE OF BIRTH
SOCIAL SECURITY NUMBER
GENDER
 Male
 Female
GUARDIANSHIP STATUS
 Biological Parent
 Non-Parent Relative
 DCS Custody
 Other
HOME ADDRESS
CITY
STATE and ZIP CODE
HOME PHONE
CELL PHONE
WORK PHONE
FATHER’S NAME
FATHER’S DATE OF BIRTH
FATHER’S SOCIAL SECURITY NUMBER
MOTHERS’S NAME
MOTHER’S DATE OF BIRTH
MOTHER’S SOCIAL SECURITY NUMBER
PRIMARY CONTACT’S EMAIL ADDRESS
PATIENT’S EMPLOYMENT STATUS
 Employed – Full Time
 Employed – Part Time
 Student – Full Time
 Student – Part Time
SCHOOL
COUNTY
CURRENT GRADE
PHYSICIAN REFERRAL INFORMATION
PRIMARY CARE PHYSICIAN
PHYSICIAN PHONE NUMBER
RESPONSIBLE PARTY and INSURANCE INFORMATION
POLICY HOLDERS NAME
RELATIONSHIP TO PATIENT
POLICY HOLDERS DATE OF BIRTH
POLICY HOLDERS SOCIAL SECURITY NUMBER
POLICY HOLDERS HOME NUMBER
POLICY HOLDERS WORK NUMBER
POLICY HOLDERS HOME ADDRESS
CITY
STATE and ZIP CODE
POLICY HOLDERS EMPLOYER
EMPLOYERS PHONE NUMBER
INSURANCE CARRIER
POLICY NUMBER
GROUP NUMBER
EMERGENCY CONTACT INFORMATION
LAST NAME
FIRST NAME
RELATIONSHIP TO PATIENT
HOME NUMBER
CELL NUMBER
WORK NUMBER
METHODS OF COMMUNICATION
 Yes
 No
DO WE HAVE PERMISSION TO CONTACT YOU AT WORK?
 Yes
 No
DO WE HAVE PERMISSION TO CONTACT YOU AT HOME?
 Yes
 No
DO WE HAVE PERMISSION TO SEND MAIL TO YOUR HOME?
 Yes
 No
DO WE HAVE PERMISSION TO LEAVE A MESSAGE ON YOUR ANSWERING MACHINE?
 Yes
 No
DO WE HAVE PERMISSION TO SEND YOU EMAIL?
WHERE DID YOU HEAR ABOUT RIGHTEOUS OAKS?
Submit
Patient Demographic Form
CHILD AND ADOLESCENT
Please PRINT
DATE: ____________
PATIENT INFORMATION
LAST NAME
FIRST NAME
MI
NICKNAME
DATE OF BIRTH
SOCIAL SECURITY NUMBER
GENDER
 Male
 Female
GUARDIANSHIP STATUS
 Biological Parent
 Non-Parent Relative
 DCS Custody
 Other
HOME ADDRESS
CITY
STATE and ZIP CODE
HOME PHONE
CELL PHONE
WORK PHONE
FATHER’S NAME
FATHER’S DATE OF BIRTH
FATHER’S SOCIAL SECURITY NUMBER
MOTHERS’S NAME
MOTHER’S DATE OF BIRTH
MOTHER’S SOCIAL SECURITY NUMBER
PRIMARY CONTACT’S EMAIL ADDRESS
PATIENT’S EMPLOYMENT STATUS
 Employed – Full Time
 Employed – Part Time
 Student – Full Time
 Student – Part Time
SCHOOL
COUNTY
CURRENT GRADE
PHYSICIAN REFERRAL INFORMATION
PRIMARY CARE PHYSICIAN
PHYSICIAN PHONE NUMBER
RESPONSIBLE PARTY and INSURANCE INFORMATION
POLICY HOLDERS NAME
RELATIONSHIP TO PATIENT
POLICY HOLDERS DATE OF BIRTH
POLICY HOLDERS SOCIAL SECURITY NUMBER
POLICY HOLDERS HOME NUMBER
POLICY HOLDERS WORK NUMBER
POLICY HOLDERS HOME ADDRESS
CITY
STATE and ZIP CODE
POLICY HOLDERS EMPLOYER
EMPLOYERS PHONE NUMBER
INSURANCE CARRIER
POLICY NUMBER
GROUP NUMBER
EMERGENCY CONTACT INFORMATION
LAST NAME
FIRST NAME
RELATIONSHIP TO PATIENT
HOME NUMBER
CELL NUMBER
WORK NUMBER
METHODS OF COMMUNICATION
 Yes
 No
DO WE HAVE PERMISSION TO CONTACT YOU AT WORK?
 Yes
 No
DO WE HAVE PERMISSION TO CONTACT YOU AT HOME?
 Yes
 No
DO WE HAVE PERMISSION TO SEND MAIL TO YOUR HOME?
 Yes
 No
DO WE HAVE PERMISSION TO LEAVE A MESSAGE ON YOUR ANSWERING MACHINE?
 Yes
 No
DO WE HAVE PERMISSION TO SEND YOU EMAIL?
WHERE DID YOU HEAR ABOUT RIGHTEOUS OAKS?
Submit