Mercy Clinic Children’s Respiratory and Sleep Medicine
REGISTRATION FORM

Date of Appointment: ___________________

PATIENT DEMOGRAPHICS	

Name: _________________________________________________	SSN: _________________________________

Sex:  Male    Female	Birth date: _____________________	Nickname/Preferred Name: 
									______________________________________
Patient Address
Address: ________________________________________________	Home Phone: ___________________________
	  ________________________________________________	Work Phone: ___________________________
City: 	  ________________________________________________	Cell Phone: ____________________________
State:	  ________________		Zip: ____________________	E-mail: ________________________________

Best Contact # for Appointment Reminders:______________________________________________________________

Preferred Communication Method:    Mail            My Mercy

Mother Name:_______________________________________           Home Phone:_____________________________
DOB:_____________________                                                             Work Phone:______________________________
                                                                                        		        Cell Phone:_______________________________	

Father Name:_______________________________________           Home Phone:______________________________
DOB:_____________________					        Work Phone:______________________________
								        Cell Phone:_______________________________						   	
□ Married		   □ Separated			□ Divorced  			□ Life Partner

Biological Siblings (list names):__________________________________________________________________________________________

________________________________________________________________________________________________

PRIMARY CARE PROVIDER INFORMATION	

Pediatrician: ________________________________________________
Phone Number:______________________________________________
Referring Doctor’s Name:______________________________________
Referring Doctor’s Phone number:_______________________________

RESPONSIBLE PARTY/GUARANTOR	

Name: _____________________________________________  DOB: _____________  SSN:______________________
Address: _____________________________________________
	  _____________________________________________
City: 	  _____________________________________________
State: 	  __________________		Zip: _________________	Phone: ________________________________
Relationship to Patient: ______________________________________________________________________________

EMERGENCY CONTACT INFORMATION(Other than parents)	

Name: _________________________________________________	Home Phone: ___________________________
Address: _______________________________________________	Work Phone: ___________________________
	  _______________________________________________	Cell Phone: ____________________________
	  _______________________________________________	Relationship to Patient: ___________________
City: 	  _______________________________________________	State: _____________________Zip:_________ 

SUBSCRIBER ACCOUNT INFORMATION	

Insurance Coverage (Medicaid Patients:Subscriber is ALWAYS the patient)
Insurance Name:____________________________ Secondary Insurance Name:______________________________
Insurance Effective Date:_____________________  Secondary Insurance Effective Date:________________________	
Subscriber Name:___________________________  Secondary Subscriber Name:_____________________________ 
Subscriber DOB:____________________________ Secondary Subscriber DOB:_______________________________
Subscriber Employer:________________________  Secondary Subscriber Employer:___________________________