Patient Registration  

Please provide the following information and we will process your childs registration immediately. We will need for you to fax or bring into the office the following pieces of information. Insurance Cards and Drivers License or State ID Card. You may fax to : 480-247-5241

Thank You

Childs First Name
Childs Last Name
Birth Date
Address 1
Address 2
City
State
Zip
Phone
Parental Information  
Child Resides With




Mothers Name
Fathers Name
Mothers DOB
Fathers DOB
Mothers Employer
Fathers Employer
Mothers Employer Phone
Fathers Employer Phone
Mother Cell Phone
Fathers Cell Phone
Parents Email Address
Insurance Information  
Primary Insurance
Policy Number
Group Number
Subscriber Name 
Subscriber DOB
Relation to Primary Subscriber

 
Secondary Insurance
Secondary Policy No.
Secondary Group No.
Secondary Subscriber
Secondary Subscriber DOB
Relation to 2ndry Subscriber

In Case of Emergency

 
Contact Person
Relation to Patient
Phone 1
Phone 2
Email 
The Above Information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Premier Pediatric Group Inc. or insurance company to release any information required to process my claims 
Authorization

Last Four Numbers of SS#