To print: Click here or Select File and then Print from your browser's menu

El Camino Pediatrics:  Patient Information Sheet

*office use only
DOC:  __________________
Date:   __________________
Time:    _________________
Today's Date:   ____________
Mother or Guardian
SS# DOB
Father or Guardian
SS# DOB
Address
Street
City State Zip
Phone     
Home Cell
Phone     
Father's Work Mother's Work
Mother's Employer
Father's Employer  
Who Referred You?
List ALL
Children's
Names		 S
E
X		 Birth
Date		 *OFFICE
USE ONLY
       
       
       
       
       
       
       
       
       
Friend or relative not living with you
(for emergency use only)
Name Phone
Primary
Insurance Company
Primary
Insured's name
Insurance ID #
Policy or Group#
Effective Date
Other Insurance




Insurance Company Address
Street
City State Zip
The undersigned agrees that all services are rendered on a paid basis only.  Our policy is to collect for services at the time they are rendered.  If collection becomes necessary, the undersigned shall pay all reasonable costs.

We will bill insurance for those companies that we have a contractual obligation to do so.  The undersigned agrees to authorize insurance benefits to be paid directly to the physician.  The undersigned is responsible for all non-covered services.  The undersigned authorizes the physician to provide any information required to process claims for benefits.

Parents agree to have chart notes copied and forwarded when requested by a specialist of school.
Mother or Guardian
Father or Guardian