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Home
Meet Our Doctors
Meet Dr. Remy
Meet Dr. Rahming-O’Neil
Services
Forms
PATIENT REGISTRATION FORM
PRENATAL CONSULTATION
COVID QUESTIONNAIRE
Our Office
Podcast
Meet Our Staff
Videos
Book an Appointment
PATIENT REGISTRATION FORM
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PATIENT REGISTRATION FORM
Please fill in the information completely, and print clearly. Welcome to the Kiddiatrix Family!!
Patient Information:
Child's Name (First, Middle, Last):
DOB (dd/mm/yyyy):
Street Address:
Home Number
Primary Insurance Co.:
Name of Insured:
Secondary Insurance Co.:
Name of Insured:
Gender:
Male
Female
Postal Address:
Child Lives with:
Group No.:
ID No.:
Group No.:
ID No.:
Primary Caregiver Details
Name in Full:
Relationship:
Mother
Father
Other
Home Phone
Work Phone
Cell Phone
Preferred Communication:
Email
Cell
Home #
If Other, enter relationship here
DOB (dd/mm/yyyy):
Address:
Email
Secondary Caregiver Details
Name in Full:
Relationship:
Mother
Father
Other
Home Phone
Work Phone
Cell Phone
Preferred Communication:
Email
Cell
Home #
If Other, enter relationship here
DOB (dd/mm/yyyy):
Address:
Email
Emergency Contact (Other than parents):
Name:
Relation to the child
Home Phone
Work Phone
Cell Phone
I authorize Kiddiatrix at Sandyport Medical Centre to treat my child. I further authorize the release of medical information necessary for the completion of insurance forms. I authorize payment directly to Kiddiatrix at Sandyport Medical Centre by my insurance company for any and all medical benefits in settlement of claims sent to my insurance. I understand that I am financially responsible for all charges. If I have insurance coverage, that includes co-payments and any charges not covered under my insurance benefits.
Guarantor's Name
Today's Date
Signature
Submit
