CORNERSTONE PEDIATRICS

76 Remick Blvd.

Springboro, Ohio 45066

PATIENT NAME: ________________________ Sex: M F Date of Birth: __________
Address: _____________________________ City: ________________ State: ________
Zip: ___________ Home Phone: ____________________ SS#: ____________________

MOTHER’S NAME: ____________________________ Date of Birth: ______________
Address: _____________________________ City: ________________ State: ________
Zip: ___________ Home Phone: _________________ Cell Phone: _________________
SS#: _________________ Employer: ___________________ Phone: _______________

FATHER’S NAME: ____________________________ Date of Birth: ______________
Address: _____________________________ City: ________________ State: ________
Zip: ___________ Home Phone: _________________ Cell Phone: _________________
SS#: _________________ Employer: ___________________ Phone: _______________

FINANCIALLY RESPONSIBLE PARTY INFORMATION

Name: _____________________________ Address: _____________________________
City: _________________________ State: _______________ Zip: _________________
Home Phone: ________________________ Cell Phone: __________________________
SS#: _________________ Employer: ___________________ Phone: _______________

INSURANCE INFORMATION

Primary Insurance Name: _______________________ Policy Number: ______________
Policy Holder: _______________________ Sex: M F SS#: ______________________
Date of Birth: ___________________ Relationship to Child: ______________________
Insurance Address: ________________________________________________________

Secondary Insurance Name: _____________________ Policy Number: ______________
Policy Holder: _______________________ Sex: M F SS#: ______________________
Date of Birth: ___________________ Relationship to Child: ______________________
Insurance Address: ________________________________________________________

I HEREBY CONSENT TO THE ADMINISTRATION OF SUCH MEDICAL CARE AND TREATMENT AS DETERMINED APPROPRIATE BY CORNERSTONE PEDIATRICS, LLC, FOR THE ABOVE MINOR. I AUTHORIZE THE RELEASE OF ANY MEDICAL RECORDS FOR CONTINUITY OF CARE OR BILLING PURPOSES. IN ADDITION, I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO BE MADE DIRECTLY TO CORNERSTONE PEDIATRICS, LLC, FOR SERVICES PERFORMED.

Parent’s Signature: ________________________________ Date: ___________________

Dear Parent or Guardian,

We understand that it is not always possible for you to bring your child to our office for care and that you may wish to send them with family members or close friends. Please take the time to fill out the following form carefully. List the names of those individuals that you will allow to make appointments and/or bring your child to our office for well and sick visits. Please understand that we will not treat your child if he/she is brought to our office with someone other than a parent or guardian unless we get your written permission in advance.

I hereby authorize the following individuals to make appointments and/or bring my child to Cornerstone Pediatrics to receive care from all physicians and staff as needed for sick and well care if I am unable to accompany him/her. I do understand that insurance co-payments or full payment is due at the time of the visit, regardless of who brings the child to the appointment.

Name: _____________________________ Phone:__________________

Relationship to Patient: ___________________

Name: _____________________________ Phone:__________________

Relationship to Patient: ___________________

Name: _____________________________ Phone:__________________

Relationship to Patient: ___________________

EMERGENCY CONTACT INFORMATION

Please list the name, relationship, and phone number of at least two people not living with you who we may contact in the event of an emergency.

1. Name: _______________________________ Relationship: ________________

Address: _________________________ City:________ State:____ Zip: ______

Home Phone: ______________________ Cell Phone: ___________________

2. Name: _______________________________ Relationship: ________________

Address: _________________________ City:________ State:____ Zip: ______

Home Phone: ______________________ Cell Phone: ___________________

3. Name: _______________________________ Relationship: ________________

Address: _________________________ City:________ State:____ Zip: ______

Home Phone: ______________________ Cell Phone: ___________________

Parent’s Signature: ______________________________ Date: __________