Patient Registration Form Step 1 of 7 14% Parent or Guardian InformationParent/Guardian (Primary Contact) Legal Name First Last Relation to Paitent BirthdayMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SSNLive w/ Patient? Yes No Preferred Phone #Phone # Type Cell Home Work Second Phone #Phone # Type Cell Home Work Other Phone #Phone # Type Cell Home Work Parent or Guardian InformationParent/Guardian (Secondary Contact) Legal Name First Last Relation to Paitent BirthdayMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SSNLive w/ Patient? Yes No Preferred Phone #Phone # Type Cell Home Work Second Phone #Phone # Type Cell Home Work Other Phone #Phone # Type Cell Home Work Parent or Guardian InformationEmail Appointment reminders- we will attempt to contact you to remind you of upcoming appointments. If you wish to receive an additional automated reminder, please choose ONLY ONE of the options below Text Phone Call Email as written above Text #Phone Call #Primary Address for all children listed below Street Address Apt City State Zip Patient Information –list all children who are or will be seen at our clinic Legal First Name Legal Last Name MI BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex/Gender Doctor Ethnicity Hispanic or Latino Not Hispanic or Latino Preferred Language English Other Race American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Type "Other" language below Patient Information –list all children who are or will be seen at our clinic Legal First Name Legal Last Name MI BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex/Gender Doctor Ethnicity Hispanic or Latino Not Hispanic or Latino Preferred Language English Other Race American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Type "Other" language below Patient Information –list all children who are or will be seen at our clinic Legal First Name Legal Last Name MI BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex/Gender Doctor Ethnicity Hispanic or Latino Not Hispanic or Latino Preferred Language English Other Race American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Type "Other" language below Emergency Contact Information - Please list a friend or relative NOT living with you. For emergency use only. Name First Last Relation Phone #Privacy Practices I acknowledge that the Physician’s Notice of Privacy Practices has been offered to me. The Notice of Privacy Practices provides detailed information about how the practice may use and disclose my or my child’s confidential information. I understand that the physician has reserved the right to change his or her privacy practices that are described in the Notice. I also understand that a copy of any Revised Notice will be provided to me or made available to me. Financial Policy I acknowledge that I am aware of East Portland Pediatric Clinic’s financial policy and will be given a copy upon request. Financial Policy I hereby authorize the physicians of East Portland Pediatric Clinic, P.C. to provide such medical services, regular or emergency, as may be determined to be in the best interest of those members of my immediate family, as listed above, who are minors. This authorization shall continue and be in full force and effect until revoked in writing by me. Signature Relationship to Patient DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920How did you hear about our clinic? Please check all that apply. Friend Family Parent seen here as child Web search Hospital OB-Gyn Advertisement Established Family Other child already a patient Insurance company CommentsThis field is for validation purposes and should be left unchanged. Δ
