Patient Information

First Name *

Middle Name

Last Name *

Patient Preferred Name *

Sex *

Other

Phone *

Email *

Sibling(s)

Please provide the names, sex, and DOB of all siblings.

SIBLING (1)

Sex

Male

Female

Other

Date of Birth

SIBLING (2)

Sex

Male

Female

Other

Date of Birth

SIBLING (3)

Sex

Male

Female

Other

Date of Birth

SIBLING (4)

Sex

Male

Female

Other

Date of Birth

Mother/ Primary Guardian

Mother/ Primary Guardian Name *

Mother/Primary Guardian Occupation *

PRIMARY HOME/MAILING ADDRESS *

Home Phone Number

Mobile phone number *

Email Address (please use LOWERCASE only) *

Father/Secondary Guardian

Name *

Father/Secondary Guardian Occupation *

PRIMARY HOME/MAILING ADDRESS *

Home Phone Number

Mobile Phone Number *

Email Address (please use LOWERCASE only) *

Emergency Contacts

Please list (2) emergency contacts that we can notify in the event that parents/guardians are not available.

CONTACT (1) *

Emergency Contact Phone # *

Emergency Contact Relationship to Patient *

CONTACT (2) *

Emergency Contact Relationship to Patient (2) *

Emergency Contact Phone (2) *

Insurance

Pleae note that we accept most major PPO plans (United, Cigna, Aetna, Blue Cross, Blue Shield).

Do you have Insurance? *

Yes

Primary Insured Relationship to Patient

Primary Insured

Primary Insured DOB

Insurance Company Name

Group Name

Group Number

Insurance ID #

Do you have Secondary Insurance? *

Yes

Secondary Insured Relationship to Patient

Secondary Insured

Secondary Insured DOB

Insurance Company Name

Group Name

Group Number secondary insured

Insurance ID #

Medical Consent Form for Child

If you anticipate that your child will be transported and supervised by individuals that are not the parents when visiting the office, then please complete the form below.

Medical Consent *

I, the parent or legal guardian, do hereby consent to any medical care determined by a physician to be necessary for the welfare of my child when accompanied and supervised by the following individuals.

Please list the NAMES and RELATIONSHIP to patient for all authorized individuals below:

Telemedicine Consent Form

HIPAA Consent Form

I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.

Parent/Guardian Name *

Date *

CREDIT CARD AUTHORIZATION FORM

Our office requires that a credit card be kept on file for payment of any co-payment, co-insurance, deductible, or charge that may not be covered by your health insurance. This form will be kept confidential and only authorized staff has access to the information.

NAME, AS IT APPEARS ON CREDIT CARD: *

BILLING ADDRESS: *

AMEX/DISC/MC/VISA CARD # *

VERIFICATION CODE (3 or 4 DIGITS) *

EXPIRATION DATE: *

PLEASE PROVIDE THE CARDHOLDER’S DRIVER’S LICENSE #

I acknowledge and authorize Sam Kim Physician Services, Inc to charge the above credit card account for any co-payment, co-insurance, deductible and/or charges not covered by my health insurance provider. I acknowledge that my card will be run in the event payment is not received within thirty days after I receive a statement. I agree to receive billing statements, invoices and receipts via the email I have provided to this office. If I am an uninsured patient I authorize payment at time of service. I agree to update any information regarding this credit card account.

Cardholder Name *

Date *

ADMINISTRATIVE FEE

Admin Fee Consent *

I have read and understand the administrative fee information and agree to the terms of Robertson Pediatrics annual administrative fee policy. I agree to pay this fee for items and services not covered and not reimbursed by my insurance plan.

Parent/Guardian Name *

Date *

Cancellation Policy

Fees must be paid prior to the patients' next visit. *

I do hereby consent and acknowledge my agreement to the terms set forth in the CANCELLATION POLICY. I understand that this consent shall remain in force from this time forward. I acknowledge and authorize Sam Kim Physician Services, Inc to charge my credit card account for any penalties related to the failure in cancelling/rescheduling appointments within 24 hours of the visit.

Parent/Guardian Name *

Date *