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Heart Center For Children
PLEASE COMPLETE ALL SECTIONS
PATIENT INFORMATION
Male ______ Female ______
______________________________________________
Last
First
MI
___________________ ___________
Date of Birth
Age
___________________________________________ __________________________ ____________
Address
Apt
City
State
Zip Code
(____)_______________ ________________
Home Phone
SSN if over 18 years
______________________ (____)____________
Employer (if applicable)
Work Phone
GUARANTOR INFORMATION (PARENT/SPOUSE WHO CARRIES INSURANCE)
Relationship to Patient:
( ) Mother ( ) Father ( ) Spouse ( ) Guardian
__________________________________________
Last
First
MI
_________________ ______________
Date of Birth
SSN
___________________________________________ __________________________ ____________
Address
Apt
City
State
Zip Code
(____)_______________ ________________
Home Phone
Employer
(____)__________________
Work Phone
_______________
Driver’s License #
OTHER PARENT
Relationship to Patient:
( ) Mother ( ) Father ( ) Spouse ( ) Guardian
__________________________________________
Last
First
MI
_________________ ____________
Date of Birth
SSN
___________________________________________ __________________________ ____________
Address
Apt
City
State
Zip Code
(____)_______________ ________________
Home Phone
Employer
(____)__________________
Work Phone
________________
Driver License #
REFERRING DOCTOR INFORMATION
_____________________________________
Patient’s Referring Physician
(____)________________ ___________________
Phone #
City
PRIMARY CARE PHYSICIAN (if different than referring doctor)
____________________________________
(____)__________________ ________________
Patient’s Primary Care Physician
Phone Number
New Patient Child
(age Birth-18 Years)
Updated JUL 2012
Date
7777 Forest Lane • Suite B-320 • Dallas, Texas 75230 • (972) 566-4299 • Fax (972) 566-4210
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Heart Center For Children
INSURANCE INFORMATION (Primary)
_______________________________________(____)________________________________________
Insurance Name
Phone Number
Policy Number
Group #__________________________
____HMO ____PPO ____Indemnity
____Traditional
INSURANCE INFORMATION (Secondary)
____________________________________________________________________________________
Insurance Name
Phone Number
Policy Number
GROUP #__________________________
____HMO ____PPO ____Indemnity ____Traditional
CREDIT POLICY
All services by this association are charged directly to the patient. We will be happy to file all necessary
insurance forms at no charge and credit their payments to your account. Although we may be contracted
with your insurance carrier as a participating provider to accept a contracted rate for services, your deductible
or the percentage not covered by the insurance is due at the time services are rendered. If we are not a
participating provider on your insurance plan or if you do not have medical insurance, payment
arrangements must be made prior to services being rendered. If you are on an HMO insurance plan or
certain POS insurance plans, it is your responsibility to make certain we have a valid referral from your
primary care physician prior to your appointment. If we do not have the referral at the time of the
appointment, you will be responsible for payment of the services in full on the date of service or we will
happy to reschedule your appointment. Your signature below indicated that you understand that payment of
your charges are ultimately your responsibility and agree to comply with this policy.
_______________________________________
Signature
_____________________
Date
ASSIGNMENT FOR MEDICAL BENEFITS AND MEDICAL INFORMATION RELEASE
I hereby assign and transfer all of my rights, title and interest of my medical reimbursement benefits with my
medical insurance company to The Heart Center for Children. This authorization furthermore entitles The
Heart for Children to forward medical records to my insurance company at their request.
_______________________________________ _______________________
Signature
Date
New Patient Child
(age Birth-18 Years)
Updated JUL 2012
7777 Forest Lane • Suite B-320 • Dallas, Texas 75230 • (972) 566-4299 • Fax (972) 566-4210
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Heart Center For Children
PATIENT MEDICAL HISTORY
List the reason for today’s appointment:_______________________________________________________
List All PAST illnesses, hospitalizations, surgeries and medical problems your child has had:
_______________________________________________________________________________________
_______________________________________________________________________________________
List All MEDICATIONS WITH THE CURRENT DOSAGE your child is taking:
_______________________________________________________________________________________
_______________________________________________________________________________________
List all medications your child is allergic to and the reaction caused by the allergy:
(example: Penicillin – Skin Rash)
_______________________________________________________________________________________
List any known developmental or socialization problems your child has:
_______________________________________________________________________________________
Are your child’s immunizations up to date?
Yes ____
No ____
Is there any other history or information regarding your child that we should know?
_______________________________________________________________________________________
PATIENT FAMILY HISTORY
CIRCLE ALL THAT APPLY
Heart Murmur or Congenital Heart Disease: Mom-Dad-Brother-Sister-Maternal GrandmotherMaternal Grandfather-Paternal Grandmother-Paternal Grandfather
Syncope (fainting):
Mom-Dad-Brother-Sister-Mat Grandmother-Mat Grandfather-Pat Grandmother-Pat Grandfather
Diabetes:
Mom-Dad-Brother-Sister-Mat Grandmother-Mat Grandfather-Pat Grandmother-Pat Grandfather
High Blood Pressure:Mom-Dad-Brother-Sister-Mat Grandmother-Mat Grandfather-Pat Grandmother-Pat Grandfather
Stroke:
Mom-Dad-Brother-Sister-Mat Grandmother-Mat Grandfather-Pat Grandmother-Pat Grandfather
Seizures:
Mom-Dad-Brother-Sister-Mat Grandmother-Mat Grandfather-Pat Grandmother-Pat Grandfather
continued on Page 4
New Patient Child
(age Birth-18 Years)
Updated JUL 2012
7777 Forest Lane • Suite B-320 • Dallas, Texas 75230 • (972) 566-4299 • Fax (972) 566-4210
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Heart Center For Children
PATIENT FAMILY HISTORY …continued from Page 3
Coronary Artery Disease: Mom-Dad-Brother-Sister-Mat Grandmother-Mat Grandfather-Pat GrandmotherPat Grandfather
Mom-Dad-Brother-Sister-Mat Grandmother-Mat Grandfather-Pat Grandmother-Pat Grandfather
Asthma:
Elevated Cholesterol: Mom-Dad-Brother-Sister-Mat Grandmother-Mat Grandfather-Pat Grandmother-Pat Grandfather
Sudden Death:
Mom-Dad-Brother-Sister-Mat Grandmother-Mat Grandfather-Pat Grandmother-Pat Grandfather
Arrhythmia (irregular heartbeat): Mom-Dad-Brother-Sister-Mat Grandmother-Mat Grandfather-Pat GrandmotherPat Grandfather
Other Pertinent Family History: ___________________________________________________________
_____________________________________________________________________________________
PATIENT SOCIAL HISTORY
Does your child attend: (circle one) daycare / school (grade ______) / Other ______________
If none of the above, where does your child stay during the day? ________________________
Who does child live with? Mom _____ Dad ______ Both ______ Other _________________
Does anyone smoke in the home?
Additional siblings in the home?
No _____ Yes ____ If yes, who? ___________________
None ______
Brother(s) ______________________________ Sister(s) ______________________________
Age(s)
______________________________ Age(s)
Are there any pets in the home?
______________________________
Dog _____ Cat _____ Bird _____ Other ______________
CANCELLATION AND RESCHEDULING POLICY
The office requires a 24-hour notice to cancel/reschedule an appointment. Failure to do so will result in a
$25.00 charge.
__________________________________
Signature
_______________________
Date
I have read the Privacy Policy (HIPAA) for this office __________________________________________
Signature
New Patient Child
(age Birth-18 Years)
Updated JUL 2012
7777 Forest Lane • Suite B-320 • Dallas, Texas 75230 • (972) 566-4299 • Fax (972) 566-4210
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