NORTHPOINT PEDIATRICS

PATIENT REGISTRATION FORM

Patient's Full Name

Preferred Name

Date of Birth

Sex Assigned at Birth

Gender Identity

ETHNICITY (Please select one)

L Latino/Hispanic

X Not Hispanic or Latino

O Other

N Refuse

SIBLINGS

Full Names/dates of birth/genders separated by commas

Initial	Please read, initial, and sign below
	Privacy Policy: I acknowledge that I have reviewed a copy of the Northpoint Pediatrics Privacy Policy.
	Failed and Canceled Appointment Policy: I acknowledge that I have reviewed and agree to comply with the Northpoint Pediatrics Failed and Canceled Appointment Policy.
	Financial Agreement: I acknowledge that I have reviewed and agree to comply with the Northpoint Pediatrics Financial Agreement.
How did you hear about us?

Legal Parent/Guardian Signature

Printed Name

Today's Date

* I understand I am able to withdraw my consent at any time by contacting Northpoint Pediatrics in writing at 9669 E 146th St, Suite 300, Noblesville, IN 46060.

PARENT & GUARANTOR INFORMATION FORM

PARENT 1 (PRIMARY POLICY HOLDER)

Name (Parent 1)

Gender (Parent 1)

Date of Birth (Parent 1)

SSN (Parent 1)

Street Address (Parent 1)

City, State, Zip (Parent 1)

Email (Parent 1, Personal-Only, no work emails) This indicates consent for communication via electronic mail.

Cell Phone (Parent 1)

Home Phone (Parent 1)

Work Phone (Parent 1)

Employer (Parent 1)

Occupation (Parent 1)

Lives with Patient
Yes No

Policy Holder
Yes No

Front of Insurance Card:

Back of Insurance Card:

Name (Parent 2)

Gender (Parent 2)

Date of Birth (Parent 2)

SSN (Parent 2)

Street Address (Parent 2)

City, State, Zip (Parent 2)

Email (Parent 2, Personal-Only, no work emails) This indicates consent for communication via electronic mail.

Cell Phone (Parent 2)

Home Phone (Parent 2)

Work Phone (Parent 2)

Employer (Parent 2)

Occupation (Parent 2)

Lives with Patient
Yes No

Policy Holder
Yes No

Name (Step Parent 1)

Gender (Step Parent 1)

Date of Birth (Step Parent 1)

SSN (Step Parent 1)

Street Address (Step Parent 1)

City, State, Zip (Step Parent 1)

Email (Step Parent 1, Personal-Only, no work emails) This indicates consent for communication via electronic mail.

Cell Phone (Step Parent 1)

Home Phone (Step Parent 1)

Work Phone (Step Parent 1)

Employer (Step Parent 1)

Occupation (Step Parent 1)

Lives with Patient
Yes No

Policy Holder
Yes No

Name (Step Parent 2)

Gender (Step Parent 2)

Date of Birth (Step Parent 2)

SSN (Step Parent 2)

Street Address (Step Parent 2)

City, State, Zip (Step Parent 2)

Email (Step Parent 2, Personal-Only, no work emails) This indicates consent for communication via electronic mail.

Cell Phone (Step Parent 2)

Home Phone (Step Parent 2)

Work Phone (Step Parent 2)

Employer (Step Parent 2)

Occupation (Step Parent 2)

Lives with Patient
Yes No

Policy Holder
Yes No