graphic: kids

Is Your Child Sick?TM

Emergencies

Medical Emergency:
Poison Control:

Office After Hours:
Call 911
(800) 222-1222

(808) 524-2575

Registration Form for Patients 18 Years and Older




Sex:



(for appointment reminders and contacting)

BILLING ADDRESS


Relationship to patient:






EMERGENCY CONTACT INFORMATION





INSURANCE INFORMATION

Is this patient covered by insurance?:

1. PRIMARY INSURANCE

Primary Insurance:








Patient’s relationship to subscriber:

Sex:


2. SECONDARY INSURANCE

Secondary Insurance:








Patient’s relationship to subscriber:

Sex:


I certify that the above information is accurate and current to the best of my knowledge. By providing my cell phone number and/or email address, I consent to Reis Pediatrics contacting me regarding my medical care via cell phone, text or email.

Credit Card Payment Authorization:











By signing below, you are agreeing to and understand the above financial agreement and that you understand, as the patient and/or guarantor described above as being the patient, that you are responsible for any charges incurred and agree to pay them as required within 30 days of receiving your billing statement.