New Patient Forms

Advance Pediatrics PLLC

9836W Yearling Road F-1300

Peoria, AZ 85383 (PH) 623-328-8664 (FAX) 623-328-9432

PATIENT INFORMATION/ DEMOGRAPHICS

Today's Date:

Patient Name:

Date of Birth:

Address:

Street/PO Box:

City:

State:

Zip Code:

Tel#:

E-mail address:

Pharmacy (Specify location):

Father's Name:

Father's Tel#:

Address:

Street/PO Box:

City:

State:

Zip Code:

Father's Employer:

Mother's Name:

Tel#:

Mother's Employer:

Tel#:

Person to contact in case of emergency:

Relationship:

Address:

Street/PO Box:

City:

State:

Zip Code:

Tel#:

Insurance Information:

1. Insurance Company (Copy of Card required):

Name of Insured:

Date of Birth:

Social Security #:

Policy #:

Group #:

2. Insurance Company (Copy of Card required):

Name of Insured:

Date of Birth:

Social Security #:

Policy #:

Group #:

3. AHCCCS ID#:

Plan Name (Copy of Card required):

All services furnished are charged directly to you and you are personally responsible for payment at the time the service is rendered. We will bill your insurance carrier as a courtesy. I (we) herby agree to pay for services rendered to the above mentioned patient as and when charges are incurred. In the event of default I (we) promise to pay any legal interest together with collections cost and reasonable attorney fees on the indebtedness as may be required to effect collection notice.

Name:

Relationship:

Date:

Advance Pediatrics PLLC

9836W Yearling Road F-1300

Peoria, AZ 85383 (PH) 623-328-8664 (FAX) 623-328-9432

PATIENT INFORMATION/ DEMOGRAPHICS

Insurance Information:

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