Holly City Pediatrics

New Patients

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Welcome to the Team!

Thank you for considering our practice! Feel free to stop by the office to meet the doctors and staff. If you are already convinced that we are right for you and want to spend less time in the waiting room (who wouldn't), then please fill out the New Patient Form below and click submit.

 

Accepted Insurance:

All major insurance providers are accepted (except Amerigroup)

 
 

New Patient Form

Note: Please complete this form in one sitting. If you click the back button before clicking submit, all parts filled out will be deleted

Date *
Date
Patient Name *
Patient Name
Patient Birthdate *
Patient Birthdate
Patient Phone # *
Patient Phone #
guardian phone number is okay
Patient's Insurance Company
if none, write "none"
not required
Subscriber
Responsible Party
Address
Address
(if different than patient's)
Birth Date *
Birth Date
Phone Number *
Phone Number
Do you have legal custody of the child? *
Is child adopted or a foster child? *
Mother
Name *
Name
Address
Address
if different from patient's
if unemployed, write "unemployed"
Birthdate *
Birthdate
Home Phone *
Home Phone
Work/Cell Phone *
Work/Cell Phone
Father
Name
Name
Address
Address
if different from patient's
in unemployed, write "unemployed"
Birthdate *
Birthdate
Home Phone *
Home Phone
Work/Cell Phone *
Work/Cell Phone
If we are your first, write "none"
Emergency Contact Phone Number *
Emergency Contact Phone Number
Patient Release *
I certify the information that I have provided is correct. I authorize the release of medical information necessary to process insurance claims to insurance companies or their agencies (including Medicare), for the purpose of filing and payment of medical claims. I authorize payment of medical benefits to the provider. I ACKNOWLEDGE THAT INTEREST OR A FEE, AT THE PROVIDER'S CURRENT RATE, MAY BE CHARGED on all balances owed to the provider that are past due.
Please Verify all information is correct before clicking submit