Transcription of New Patient Registration Form
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New Patient Registration Form
Rainbow Pediatric Center 4788 Hodges Blvd, B-108 Jacksonville, FL 32224 Fax: New Patient Registration form Patient DEMOGRAPHICS Today s Date: ___/___/_____ Last Name: _____ First Name: _____ Nickname (goes by): _____ Date of birth: ___/___/_____ Sex: Male / Female Home Address: _____ PRIMARY location: HODGES / NOCATEE City: _____ State: _____ Zip: _____ Home Phone: (_____)_____-_____ Cell: (_____)_____-_____ Primary email: _____ BEST phone number to reach parents: 1.) Name:_____ (_____)_____-_____ home/cell Race: Asian / African American / Caucasian / American Indian / Native Hawaiian / Hispanic / other: _____ Ethnicity: Non-Hispanic / Hispanic / Refused to report Language preference: English / Spanish / Other:_____ Pharmacy Name: _____ Address: _____ Phone:_____ How did you hear about us?
no show, the patient will be discharged from the practice. Medical Records: There will be a charge of $1.00 per page for the first 25 pages and $.25 thereafter for the copying of medical records.
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