New Patient Registration Form - Cincinnati Children's

I am:*

Registering a New Patient
Needing to Update Current Patient(s)

Date*

Children

Child 1 Name

First Last

Gender

Male
Female

Birthdate

Race

(White American, Native American, Alaska Native, Asian American, Black or African American, Hawaiian, Other Pacific Islander, Latino, Biracial)

Ethnicity

Hispanic/Latino
Not Hispanic/Latino

Do you have a second child you would like to register?

Child 2 Name

First Last

Gender

Male
Female

Birthdate

Race (White American, Native American, Alaska Native, Asian American, Black or African American, Hawaiian, Other Pacific Islander)

Ethnicity

Hispanic/Latino
Not Hispanic/Latino

Do you have a third Child you would like to register?

Child 3 Name

First Last

Gender

Male
Female

Birthdate

Race (White American, Native American, Alaska Native, Asian American, Black or African American, Hawaiian, Other Pacific Islander)

Ethnicity

Hispanic/Latino
Not Hispanic/Latino

Do you have a fourth Child you would like to register?

Child 4 Name

First Last

Gender

Male
Female

Birthdate

Race (White American, Native American, Alaska Native, Asian American, Black or African American, Hawaiian, Other Pacific Islander)

Ethnicity

Hispanic/Latino
Not Hispanic/Latino

Do you have a fifth Child you would like to register?

Child 5 Name

First Last

Gender

Male
Female

Birthdate

Race (White American, Native American, Alaska Native, Asian American, Black or African American, Hawaiian, Other Pacific Islander)

Ethnicity

Hispanic/Latino
Not Hispanic/Latino

Religion

Do you need help understanding any health information given in office?

Preferred Language

Do you need an interpreter?

Preferred Pharmacy

Who is your Primary Care Provider at Cincinnati Children's?

Which location do you visit most frequently?

If Patient is over 18 years of age, we need his/her name and contact phone number.

First Last

Phone

Family Information

Parent's Name

First Last

Birthdate

Responsible Party

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone Number

Work Phone Number

Cell Phone Number

Employer

Position

Email

Parent's Name

First Last

Birthdate

Responsible Party

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone Number

Work Phone Number

Cell Phone Number

Employer

Position

Email

*Is it okay to send you information on health-related topics via email?

If someone other than the parent is the responsible party, please fill out the following information:

Responsible Party's Name

First Last

Birthdate

Responsible Party

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone Number

Work Phone Number

Cell Phone Number

Employer

Position

Email

Primary Insurance

Insurance Company Name

Effective Date

Policy Holder Name

First Last

Birthdate

Social Security Number

Relationship to Patient

Employer Name

Group Number

Policy/ID Number

Copay Amount or % of visit

Secondary Insurance

Insurance Company Name

Effective Date

Policy Holder Name

First Last

Birthdate

Social Security Number

Relationship to Patient

Employer Name

Group Number

Policy/ID Number

Copay Amount or % of visit

Additional Information

Name of Male Step-parent (if applicable)

First Last

Legal Male Guardian (if applicable)

First Last

Relationship to Patient

Name of Female Step-parent (if applicable)

First Last

Legal Female Guardian (if applicable)

First Last

Relationship to Patient

Emergency Contact Information

Whom to Call in Case of an Emergency? (Other than parents)

Name

First Last

Relationship to Patient

Home

Work

Cell

Signature Required

I hereby authorize Cincinnati Children's to submit a claim to my insurance carrier or its intermediaries for all covered services rendered by Cincinnati Children's health care providers and hereby direct my insurance carrier or its intermediaries to issue payment directly to Cincinnati Children's on behalf of such rendered services. I understand that I am financially responsible to this office for any balance not covered by my insurance carrier. I further certify that I have had the opportunity to read and/or receive a copy of the Cincinnati Children's Privacy Policy document.

Electronic Signature

First Last

Date

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Name

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