4106 Columbia Rd, Ste 103 3121 Peach Orchard Rd, Ste 102 5135 Wrightsboro Rd, Suite B

4106 Columbia Rd, Ste 103 3121 Peach Orchard Rd, Ste 102 5135 Wrightsboro Rd, Suite B Martinez, GA 30907 Augusta, GA 30909 Grovetown, GA 3081 Phone: 706 -863-1440 Phone: 706-792-5040 Phone: 706-941-8300 Fax: 706-863-5418 Fax: 706-792-5045 Fax: 706-941-8310

PATIENT REGISTRATION FORM Please complete ALL fields with current information. Authorization I/we have the legal right to preauthorize Covenant Pediatrics to deliver medical treatment to my/our child(ren). I/we request and authorize Covenant Pediatrics and its personnel to deliver medical care to my (our) child listed below.

Patient’s Legal Name: ______Patient SSN: ______

Address: ______City______State______Zip______

Date of Birth (Mo/Day/Year):______Sex (Circle): M F Pharmacy of Choice ______

I prefer getting appointment reminders by: (please circle one) text phone email

Phone/text#: ______email______

FAMILY INFORMATION (please circle one)

Patient lives with: Mom Dad Both Other (Please Specify)______

Mom/Legal Guardian: ______Dad/Legal Guardian: ______

DOB: ______SSN:______DOB: ______SSN:______

Address (if different):______Address (if different):______

______

Hm Phone: (_____)______Hm Phone: (_____)______

Work: (____)______Cell: (____)______Work: (____)______Cell: (____)______

Email: ______Email: ______

Parent’s Marital Status (Circle): Married Widowed Divorced Single Legally Separated Other

Siblings ______DOB______DOB______

______DOB______DOB______

Emergency Contact:______Phone: ______Relationship:______**PLEASE READ ALL INFORMATION CAREFULLY** Preauthorization to Treat Minors and Permission to Discuss Protected Health Information If I/we cannot be present with my child for medical treatment, I/we give permission for the person/persons listed below to authorize medical treatment for my child. I/we understand that protected health information (PHI) may be shared with the authorized individual to assist them in making informed medical decisions.

Limitations Identify any limitations on the medical services that may be given or the time frame for which this authorization is given. If none, write “none.”

Name: ______Relationship to Patient: ______

I agree that the above information is true and correct to the best of my knowledge.

Print Name: ______Signature: ______

Date: ______Relationship to above patient: ______