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Child Under 10 Intake Packet

Child Under 10 Intake Form

Patient's Legal Name:

Patient's Legal Name:

First Name

First Name

Last Name

Last Name

Patient’s Chosen Name:

(if different from legal name)

Sex

Age

Date of Birth

Address

Address

Address

Address

City

City

State

State

Zip

Zip

Social Security Number

Phone

Language

Race

School Name

Grade

Teacher

Principal

Marital Status of Parents

Single

Marries

Divorced

Widowed

Father's Name

Date of Birth

Social Security Number

Phone

Employer Name and Phone Number

Mother's Name

Date of Birth

Social Security Number

Phone

Employer Name and Phone Number

Names and age of household members

Emergency Contact Name

Relationship to the Child

Emergency Contact Address

Emergency Contact Phone Number

Legal Guardian Name

Phone

Primary Insurance Name

ID Number

Group Number

Subscribers Name

Social Security Number

Date of Birth

Address

Address

Address

Address

City

City

State

State

Zip

Zip

Do you have a secondary insurance?

Yes

No

Secondary Insurance Name

ID Number

Group Number

Subscribers Name

Social Security Number

Date of Birth

Address

Address

Address

Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Patient/Guardian's Signature

Date

If you are human, leave this field blank.