Register a new family member

RAMSDELL PEDIATRICS

1031 Pemberton Hill Road, Suite 101
Apex, North Carolina 27502
919-303-2255

Patient Registration Form OP Version 8

This is a "secure" form. To ensure the privacy of your personal information, all data provided on this form is encrypted for transmission between your computer and our web server.
For your convenience, all children who share the same parent(s) or legal guardian(s) and are covered by the same insurance plan can be entered at the same time. If these factors are not the same for any of your children, you must submit a separate form for them.
In cases of divorce and/or remarriage, please provide information for the adult(s) who have legal custody (the authority to make medical decisions on the child's behalf), with the person who most often has physical custody listed first. You will have an opportunity to provide contact information for other interested adults, such as step-parents, when you visit the office.

Parent/Guardian Information

Parent/guardian 1 (most frequent contact for healthcare issues)

Relationship:

Lives with patient(s): should always be checked

Name (first, MI, last):

Address:

City/state/zip code:

Home phone:

Work phone:

Ext:

Cell phone:

Home Email Addr:

Work Email Addr:

Preferred method of communication.

Medical:

Reminder: Recall: Billing:

Parent/guardian 2 (leave address/phone blank if same as above)

Relationship:

Lives with patient(s):

Name (first, MI, last):

Address:

City/state/zip code:

Home phone:

Work phone:

Ext:

Cell phone:

Home Email Addr:

Work Email Addr:

Preferred method of communication.

Medical:

Reminder: Recall: Billing:

Insurance information

Insurance company:

Group number:

Provided through
parent/guardian:

1 2 Other

Patient (child) information

If you are expecting a child, please enter "BABY" as the first name, along with an approximate due date.

First name	MI	Last name	Sex	Birth/due date	Insurance ID