Judy Davis M.D.,F.A.A.P.

      Family Registration

 

                               

MOTHER:                                                                                  FATHER:

 

DOB:________________   Marital Status: S M D W    DOB:________________ Marital Status: S M D W


SS#:______________________________________     SS#:_____________________________________ 


Address:___________________________________    Address:__________________________________


City:________________  State:_________________   City:_________________  State:______________


Zip:____________ Tel #:______________________   Zip:___________  Tel #:_____________________


Employer:__________________________________   Employer:________________________________


Work #:____________________________________   Work #:__________________________________


Cell# _____________________________________     Cell# ____________________________________


Insurance Co:_______________________________    Insurance Co:______________________________


Group #:___________________________________   Group #:_________________________________


E-Mail Address:_______________________________________________________________________


CHILDREN


1._______________________________   M       F    DOB:________________  SS#:__________________


2._______________________________   M       F    DOB:________________ SS#:__________________


3._______________________________   M       F    DOB:________________SS#:___________________



AUTHORIZED PERSON’S CONSENT:


________  I hereby authorize treatment for my child(ren) and agree to pay all fees and charges incurred for   

                    services rendered.


________ I authorize the release of any medical information necessary for treatment and medical claims 

                   processing.


________   I authorize payment of medical benefits to this medical office.



________  I authorize messages from this office to be left on my home/cell phone message service or with a family member over 18 years old.



Signed: ________________________________________    Today’s Date:_________________________


EMERGENCY CONTACT:


Name:____________________________________  Relationship:________________________________


Address:__________________________________  Tel #:______________________________________


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