<p> 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</p><p>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.</p><p>Patient’s Legal Name: ______Patient SSN: ______</p><p>Address: ______City______State______Zip______</p><p>Date of Birth (Mo/Day/Year):______Sex (Circle): M F Pharmacy of Choice ______</p><p>I prefer getting appointment reminders by: (please circle one) text phone email </p><p>Phone/text#: ______email______</p><p>FAMILY INFORMATION (please circle one)</p><p>Patient lives with: Mom Dad Both Other (Please Specify)______</p><p>Mom/Legal Guardian: ______Dad/Legal Guardian: ______</p><p>DOB: ______SSN:______DOB: ______SSN:______</p><p>Address (if different):______Address (if different):______</p><p>______</p><p>Hm Phone: (_____)______Hm Phone: (_____)______</p><p>Work: (____)______Cell: (____)______Work: (____)______Cell: (____)______</p><p>Email: ______Email: ______</p><p>Parent’s Marital Status (Circle): Married Widowed Divorced Single Legally Separated Other</p><p>Siblings ______DOB______DOB______</p><p>______DOB______DOB______</p><p>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.</p><p>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.”</p><p>Name: ______Relationship to Patient: ______</p><p>Name: ______Relationship to Patient: ______</p><p>I agree that the above information is true and correct to the best of my knowledge.</p><p>Print Name: ______Signature: ______</p><p>Date: ______Relationship to above patient: ______</p>