Test Form

Patient Registration

Harbor Pediatrics Patient Registration

Date:

Patient’s Last Name:

Middle Initial:

First Name:

Preferred Name (if applicable):

Date of Birth:

Sex:

Current Age:

Patient’s Mailing Address:

Is your mailing address the same as your physical address? Yes No

If no, please provide physical address:

Parental Information (If patient is under 18 years old)

Parent #1 Name (primary contact):

Home Phone:

Work Phone:

Cell:

Email:

Would you like to be automatically registered to the patient portal with this email? Yes No

Parent #2 Name:

Home Phone:

Work Phone:

Cell:

Email:

Would you like to be automatically registered to the patient portal with this email? Yes No

Guardian (if not parent):

Usual Provider:

Preferred Pharmacy:

Emergency Contact Name (other than parent #1/#2):

Relationship:

Emergency Contact Phone:

Authorization to disclose information

I give Harbor Pediatrics permission to speak to:

Phone number:

Medical information
Billing information

Communication Preference

Consent to call? Yes No

Consent to text? Yes No

Contact preference:

Demographics

Language:

Do you require a translator? Yes No

Race:

Ethnicity:

Insurance

Primary Insurance Name:

Policy #:

Group #:

Policy Holder (guarantor) Name:

Same as home address?

Address of policy holder (guarantor):

Home phone:

E-mail:

DOB of policy holder (guarantor):

SSN:

Relationship of guarantor to patient:

Employer name of policy holder (guarantor):

Secondary Insurance Name:

Policy #:

Group #:

Policy Holder (guarantor) Name:

Your kids. Our commitment.

Harbor Pediatrics is an independent pediatric primary care practice that provides expert care to patients in southern Maine, seacoast New Hampshire, and surrounding communities.