KIDS DOC Preregistration Form

Please answer all of the questions to the best of your ability. To protect your privacy, your information will be sent over a secure connection.

Required fields are indicated with a red asterisk. We may need to contact you by telephone if you do not provide all requested information. If you prefer, you may download a printable version of the form and submit it by mail or fax.

Please complete the registration form at least 24 hours prior to the scheduled appointment to allow time for processing.

* indicates required field

Person submitting preregistration information

Your name	First* Last*
Phone & Email	Phone* Email*
Relationship to patient*	Mother, Father, etc

Contact preference

Occasionally we make our e-mail list available for mailings from Children's Memorial Hospital. If you prefer not to receive these, please check this box. Privacy policy.

My child is coming to Children's for

Visit type	Reason for visit* Name of department/doctor/test*
Visit date & time	Date of visit (MM/DD/YYYY)* Time*

Child's information

Legal name	First* Last*
Birth details	Date of Birth (MM/DD/YYYY)* Birth hospital (if child is less than 1 year old)
	Birth city* Birth state*
Gender*	male female
Race*	How would you like your child's race to be listed?*
Additional information	Primary language Medical record# (if known)
Home address	Line 1* Line 2 (apartment, suite, etc)
City, State, Zip	City* State* Postal code*
Phone	Home phone w/area code* Preferred phone w/area code*

Child's primary care physician

(the doctor you visit for immunizations, school physicals, etc.)

Name	First Last
Phone	Include area code

Referring physician

Name	First Last
Phone	Include area code

Information about the child's Mother

Legal name	First Last
Date of Birth & Maiden name	Date of Birth (MM/DD/YYYY) Maiden name

Information about the child's Father

Legal name	First Last
Date of Birth	MM/DD/YYYY

In case of emergency

Emergency contact	First name Last name
Additional information	Relationship to child Phone

Information about the child's legal guardian (if not parent)

Name	First Last
Additional information	Relationship to child Date of Birth (MM/DD/YYYY)
Address	Line 1 (if different from child's) Line 2
City, State, Zip	City State Postal code
Phone	Home phone w/area code Preferred phone w/area code

Child's primary insurance coverage

Subscriber name	First name Last name
Additional Details	Relationship to child Subscriber Social Security number Phone
Address	Line 1 (if different from child's) Line 2
City, State, Zip	City State Postal code
Insurance details	Insurance company as listed on card Insurance type

	Group # Policy #
	Phone # for benefits If an HMO, referral authorization #
	Site name Authorization effective dates
	Claim address 1 Claim address 2
	City State Postal code

Subscriber employment (primary insurance)

Employment	Employer Occupation
Employer address	Line 1 Line 2
City, State, Zip	City State Postal code
Phone
Employment status	Full-time Part-time

Child's secondary insurance coverage

Subscriber name	First Last
Additional Details	Relationship to child Subscriber Social Security number Phone
Address	Line 1 (if different from child's) Line 2
City, State, Zip	City State Postal code
Insurance details	Insurance company as listed on card Insurance type

	Group # Policy #
	Phone # for benefits If an HMO, referral authorization #
	Site name Authorization effective dates
	Claim address 1 Claim address 2
	City State Postal code

Subscriber employment (secondary insurance)

Employment	Employer Occupation
Employer address	Line 1 Line 2
City, State, Zip	City State Postal code
Phone
Employment status	Full-time Part-time

If the child's insurance is Medicaid

Recipient #

You can be a hero for children–a hero for life.

Join the campaign today »

For patients and families