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Newborn & Family Registration

Thank you for your interest in The Center for Advanced Pediatrics. We look forward to taking care of your family! Please complete the Family Registration Form below and submit to our office. By submitting this information online and via our secure server, you will save time at your first visit to our office. Thank you.

NEWBORN & FAMILY REGISTRATION

Parent #1

NOTE: We will be sending you a welcome email and NEED an email address for you if you wish to receive.

Parent address *

Parent 1 Preferred Phone *

Work Address

Parent #2

Parent address *

Parent 2 Preferred Phone *

Work Address

MarriedLiving TogetherSeparatedDivorcedOther

Information about your new baby:


NorwalkDarien

Dr. Jeanne MarconiDr. Jay DobosDr. Aniqa AnwarDr. Jennifer Moore (Only sees for breastfeeding issues)Dr. Christen VogelEllen Fahey, DNP, APRNAriana Komaroff, APRNMelissa Fraher, APRN

Emergency Contact Person:

Emergency Contact:

Relationship:

Phone Number

Cell Number

Names of individuals, and relationship, (other than parents) of persons whom I give permission to bring in my child and be responsible for carrying out the directives given to them by Advanced Pediatrics. Please note that the person bringing in the child is responsible for payment.

Full Name

Phone Number

Full Name

Phone Number


OB/Gyn/MidwifeFamily Member or FriendSaw one of our ads on social mediaInternet Search (Google etc.)Other

Who may we thank for referring you to us?

Insurance Information (you must provide us with a copy of your current insurance card at the first visit)

Insurance Company

Group ID#

Name of Insured

DOB of Insured

Effective Date

Insurance provided through:

EmployerPrivateStateSelf PayOther

Please select one of our physicians as your primary care physician and notify your insurance of the selection.

Name of physician shown on your card:

Authorization of Treatment and Assignment of Benefits: I authorize The Center for Advanced Pediatrics, to treat my child/children. I further authorize the release of medical information necessary for the completion of insurance forms, school & camp forms. I authorize payment directly to The Center for Advanced Pediatrics, for any and all medical or surgical benefits otherwise payable to me under the terms of my insurance. I also affirm that I will reimburse Advanced Pediatrics for any payments my insurance company may have sent to me in error. I understand that I am financially responsible for all co-payments and any charges not covered under my insurance benefits. I also understand that I am responsible for advising Advanced Pediatrics of any and all changes to my insurance. Payment of co-pays are due on date of service. Failure to pay co-pay at that time will result in an additional billing charge of $25.00. Our office requires 24 hours notice of general pediatric appointment cancellation and 48 hours for specialists. Failure to provide this notice will incur a cancellation fee.

By submitting this form you agree to the above and validity of the information.