SoFHA
Patient Forms

Health History Paperwork


Description:

The Riverside Pediatrics health history paperwork.


Code:

2.204

Issued:

08/06/2020

Revision:

1

Revised:

N/A

Related Documentation

Notice of Nondiscrimination


Thank you for choosing Riverside Pediatrics as your child's pediatrician. The first step to becoming a patient with us is to complete a new patient packet. All forms included in the packet will need to be completed in full and given to the receptionist. At this time we will request a copy of the legal guardian's driver's license and a copy of your insurance card. Once we process your new patient paperwork you will receive a letter by mail stating the date and time of your next appointment. You will receive a text message reminder two days prior to your appointment. Please reply to this text message to confirm your appointment. If you do not confirm the appointment by text, we will try to reach you by phone. If you need to cancel your new patient appoinment, you will need to do so no less than 48 hours in advance.

If you fail to keep your new patient appointment, you will NOT be rescheduled.

Regretfully, we are not in the network with TNCARE SELECT.


Patient Information







Living Situation






Birth History


General


Past History

Does your child have or ever had:


Biological Family History


You answered "Yes"/"No" to the following questions:


By typing your name in the signature field below, you consent to all of the agreements listed in this form. You furthermore agree that your submission of this form, via the "Submit Form" button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.