Patient Registration/Change Form - Lexington Pediatrics, PC

Patient Family Registration and Information Change Form

(Note for new patients: We require your registration information including medical history information before you can schedule your first appointment. Completing it online here will reduce your wait at our office. New parents: You can not pre-register your child before the birth as an exact date of birth is required.)
1.Parent/Guarantor Information (insurance card subscriber)

				Date of
				(mm/dd/yyyy)

	Check here if you are a new patient family with our practice and are registering online.
	Check here if you are an existing patient family with our practice and you are only updating your contact information.
	Check here if you are an existing patient family and are adding a child to our practice.


Note: Address fields can not include special characters such as $%.+&@() etc This address is required for new patients.



Note: All phone fields can include at most 9 extra characters of explanatory text after the phone number, like "ext 234" or "pager" or "days only".



If you are an existing patient family and have finished with updating your information, click here to go to the bottom of this form to hit the SUBMIT button.

2.Parent/Spouse/Guardian Information


				(mm/dd/yyyy)


Check here if same address and home phone as Guarantor above. (You may skip address below.)
Note: Address fields can not include special characters such as $%.+&@() etc



Note: All phone fields can include at most 9 extra characters of explanatory text after the phone number, like "ext 234" or "pager" or "days only".



If you are an existing patient family and have finished with updating your information, click here to go to the bottom of this form to hit the SUBMIT button.

3.Patient Information




(mm/dd/yyyy)





Check here if same address as Guarantor. (You may skip address below.)
Check here if same address as Guardian. (You may skip address below.)
Check here if patient lives separately.
Note: Address fields can not include special characters such as $%.+&@() etc
Home



Note: All phone fields can include at most 9 extra characters of explanatory text after the phone number, like "ext 234" or "pager" or "days only".

Please check all appropriate boxes below:
Child is 24 months old or younger. Child is older than 24 months. (skip section 6.)		Child is not adopted. Child is adopted. Date of
		Adoption: (mm/dd/yyyy)
Patient relationship to Guarantor		Where did your child live prior to adoption?
		Foster Home
		Orphanage
		Biological Family
		List any notable circumstances or medical issues prior to adoption.

4.Emergency Contact Information (in addition to names above)

Your choice: online now of in-office later? NEW PATIENT FAMILIES ARE REQUIRED TO SUBMIT A MEDICAL HISTORY FORM WITH OUR PRACTICE.
PLEASE NOTE THAT NEW PATIENT FAMILIES ARE REQUIRED TO COMPLETE A MEDICAL HISTORY FORM WITH OUR PRACTICE. We prefer that you continue completing the medical history questions below at the convenience of your computer. If you choose not to complete the information below, then you will be required to wait in our waiting room and complete the information there. Instead of completing the questions below, you also have the option to provide other medical documents to us from your physician or hospital or by mail or fax or by records transfer request which contain the requested information below. You will need to bring the documents with you to your first visit. If you decide to skip the below questions, click here to go to the bottom of this form, and then click SUBMIT. If you decide to complete the medical history questions in sections 5 through 7 below, please complete the following questions as best as you can. Leave field blank if it does not apply.

5.Family Medical History
General Health of Parent/Guarantor:
General Health of Parent/Spouse:


Please indicate if you (the patient's parents) or someone in your extended family has had any history of the following conditions, and provide any brief comment. Leave field blank if it does not apply.
Asthma		Eczema
Food Allergy		Medicine Allergy
Hayfever		Other Allergy


Heart Disease		Blood Disease
Cancer		Diabetes
Tuberculosis		Rheumatic Fever


Kidney Disease		Convulsions Epilepsy
Mental Illness		Rare/Unusual Disease
Neurological Illness

Please describe any other pertinent family medical history item not mentioned above.

6.Patient Medical History (children 24 months old and younger)
Note: Please complete the following questions as best as you can, or provide other medical documents to us from your physician or hospital or by mail or fax or by records transfer request which contain the requested information below. You can also bring the documents with you to your first visit. Leave field blank if it does not apply.
APGAR Test Results:		Duration of Pregnancy:
Birth Weight:		Birth Length:
Medications During Pregnancy:

During the mother's pregnancy, please indicate if she had any of the following complications or activities. Give detail as necessary.
High Blood Pressure		Severe Vomiting
Premature Labor		Infections Needing Antibiotics
Tobacco Use		Alcohol Use
Illegal Drug Use		Heavy Bleeding
Depression		Other Explain:

During birth, delivery, or in the newborn period, please indicate if this baby had any of the following complications. Give detail as necessary.
Jaundice		Difficulty Breathing
Premature Birth		Heart Murmur
Trauma/ Injuries		Surgeries
Seizures		Other Explain:

During this child's newborn period, please indicate their feeding and digestive routine. Give detail as necessary.
Bottle or Breast Fed:		For How Long:
Does formula easily satisfy?:
Is diet and appetite satisfactory?:
Has weight gain been normal?:

Vitamins Use		To What Age?
Flouride Use		To What Age?
Iron Use		To What Age?
Other Medications:

In this section, please indicate at roughly what age this child performed the following developmental tasks. Give detail as necessary.
Sits Unaided		Walks Unaided
Speaks more than Mama/Dada		Gets Dressed Unaided
Toilet Trained During The Day		Toilet Trained At Night

7.Patient Medical History (all children)
Note: Please bring your vaccination administration record with you to your appointment.
Note: Please complete the following questions as best as you can, or provide other medical documents to us from your physician or hospital or by mail or fax or by records transfer request which contain the requested information below. You can also bring the documents with you to your first visit. Leave field blank if it does not apply.

Describe the general health condition of this patient:
Please indicate if any of the following relate to this patient. Give detail as necessary.
Hospitalizations (describe)		Surgeries (describe)
Medicine Allergy


Heart Problems		Bleeds Easily
Trouble Gaining Weight		Trouble Losing Weight
Stomachaches		Recurrent Constipation
Recurrent Vomiting		Recurrent Diarrhea


Frequent Coughs, Colds or Croup		Frequent Ear Infections
Bronchitis		Pneumonia


Chronic Skin Problems		Hives
Asthma		Eczema
Food Allergy		Other Allergy
Hayfever		Wheezing


Convulsions/ Fainting		Dizziness
Headaches


Trauma/ Injuries		Broken Bones
Joint or Leg Pain		Orthopedic Issues


Trouble Hearing		Trouble Seeing
Trouble with Teeth


Bed Wetting		Urinary Difficulty
Vaginal Discharge		Menstrual Difficulty
Kidney Infections


Left or Right Handedness		Speech Issues
School/Learning Issues		Physical Disabilities
Developmental Delay		Behavior Problems
		Other Explain:

Other Comment:
If you would like to submit information for additional children, + hit SUBMIT below, then, when you are viewing your submission confirmation page, + hit the BACK button on your browser to bring you back to this page where you can change the patient information while retaining your parent contact information. Note: If you elect below to automatically open an appointment request window, you need to come back to the confirmation window for this page before you hit the BACK browser button to enter the additional child.
You will be asked to review the information you have provided and to sign this form when you arrive for your first appointment. New patients, check here to open a new window to request a future well appointment after you click SUBMIT below. When you hit SUBMIT below, you will be registering/updating your child named You must bring your health insurance card with you for your first visit with us.

Enter the characters you see below and click SUBMIT.

INSTRUCTIONS

NEW PATIENTS: You must complete this registration form before an appointment can be made.

Complete sections 1-7 for newborns or sections 1-5 and then 7 for older children.

"*" shaded fields are required (Guarantor name, phone and address, Patient name and DOB).

Submit this form once for each new patient you are registering. Use the BACK button after confirmation to return to this page to edit the fields for a new added patient. Please register all children coming to our practice at the same time even if they don’t currently need an appointment.

To add an additional child, complete the required fields of section 1 & 3 (Guarantor name and phone, Patient name and DOB), then complete sections 6 or 7 depending on the age of the child.

EXISTING PATIENT families can use this form to update their contact information with us or to add a new child to our practice.

To update your information, complete the required fields of sections 1 & 3 (Guarantor name and phone, Patient name). Enter ONLY the contact information that has changed into sections 1, 2, 3, and 4.

To add another child, see the instructions above.

After you have entered your information into this form, please click PRINT on your browser if you would like to copy this page for your records.

Hit SUBMIT when you are finished.

KNOW MORE

Lexington Pediatrics is committed to protecting your privacy and security while using the Internet to share medical and insurance information.

While this encryption security is not infallible, it is the highest level of security typically available for transmittal of sensitive information.

If you have specific security concerns, please contact us at (781) 862-4110.