SoFHA
Patient Forms

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

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.

Since the child described in this form is over the age of 14, they will need to sign a Proxy Access form when they come into our office.

By law, we have to collect both the child's cell phone number and email address after the reach 14 years of age. By signing this form, you confirm that the child does not have .