Pediatric Eye Care & Surgery

PEDIATRIC EYE CARE & SURGERY Sarah J. Whang, M.D. PATIENT REGISTRATION

Child’s Name______Child’s Date of Birth______Home Address______Child’s Age______City, State & Zip Code______Sex: M F Home Phone #______Name(s) of any family member(s) treated in this office______

Father’s Information Mother’s Information Circle One: Father Stepfather Foster Father Circle One: Mother Stepmother Foster Mother Name______Name______Address, if different than child’s Address, if different than child’s ______Home Telephone (____)______Home Telephone (____)______Social Security #______Social Security #______Driver’s License #______Driver’s License #______Date of Birth______Date of Birth______Employer______Employer______Occupation______Occupation______Work Telephone______Work Telephone______Cell Phone______Cell Phone______E-Mail______E-Mail______

Marital Status of Parents Circle One Single Married Divorced Separated Widowed Custody: Both Parents Father Mother Other______Child Lives With______

Name of Contact Person (Other than Parent)______Contact’s Relationship to Child______Contact’s Phone # (____)______Address______City, State & Zip Code______

Who referred you to our office?______Child’s Physician______

Financial Information Insurance Co. (1)______Insurance Co. (2)______Address______Address______City, State & Zip Code______City, State & Zip Code______Phone #______GR. #______Phone #______GR. #______Member Certificate No.______Member Certificate No.______Subscriber’s Name______Subscriber’s Name______

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES: I have received or have declined to receive a copy of the Notice of Privacy Practices.

______Signature of Responsible Person Relationship to Child Date