Family Demographic Information

Plateau Pediatrics
For each child that will be our patient, please list the child's full name, preferred name or nickname,
sex, date of birth, and Social Security number.
Last

First

MI

Nickname

Sex
M
F
M
F
M
F
M
F

DOB

Social Security Number

Home address
All correspondence regarding the above children will be sent here.
Street and PO Box

Home telephone

City

State

Daytime telephone

Zip

Name of workplace
mothers work

fathers work
cell phone

_________________________

Parental information
Please list all custodial parents and/or legal guardians of the children. Include relationship
(stepfather, foster mother, etc), whether the parent lives with the child at the above address, the
parent's date of birth and Social Security number. Please list the insurance guarantor first.
Parent/Guardian's name

Relationship

Lives with?
(yes/no)

DOB

Soc Sec #

For parents/guardians who do not live at the above "home address," please list their address (es) and
telephone number(s) below:

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Insurance information
Please refer to our patient brochure and our website (www.plateaupediatrics.com) to verify the
insurance plans for which we accept assignment.
Name of insurance company

Group number

Policy number

Primary
Insurance
Secondary
Insurance
(If applies)

Family Language preference

English

Spanish

Other ______________________________

Is the primary caregiver: Visually impaired YES NO

Hearing impaired YES NO

Privacy information
Your family's privacy is important to us. Please check any of the following that you permit:
You may leave messages (with a person or answering machine) at my home phone number
You may leave messages (with a person or answering machine) at my other daytime number
You may send mail containing my childs health information to my home address
Please list any special restrictions we should follow when communicating about your child:

Preferred pharmacy (optional)

For prescriptions, I always use the following pharmacy:
CVS (Crossville)
Kroger (FFG)
Food City (Crossville)
Medicine Shoppe
John Smith Pharmacy
Mitchell Drug
K-Mart (Crossville)
Riddle Express
Kroger (Crossville)
Rite-Aid (Crossville)

Wal-Mart (Crossville)
Walgreens (Crossville)
Other: ____________________________
I dont have a regular pharmacy

Emergency information
If I cannot be contacted in an emergency situation regarding my child's health, please notify:
Emergency contact person(s)
Relationship to my children
Telephone

I agree that, in such an emergency, the above named individual(s) may give consent for treatment and may
have access to information about my child's health and medical condition.
Signed: ________________________________________________________ Date: _______________

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