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New Patient Registration

First name

Middle Name

Last name

Address

City

State

Zip Code

Phone

Date of Birth

Sex

Race (select all that apply) * Required

American Indian/Alaskan

Asian

Black/African American

Hawaiian/Pacific Islander

White/Caucasian

Other

Ethnicity * Required

Hispanic/Latino

Non-Hispanic/Latino

Decline to specify

Previous Pediatrician (Name and Location)

Preferred Pharmacy (Name and Location)

Current Medications

Allergies

Insurance

DOB of Subscriber

Place of Birth

Delivery

Vaginal

C-section

Was mother ill during birth?

Yes

Was baby born on expected date?

Yes

Did your baby have any medical problems after being born?

Yes

Mother's Name and Occupation

Father's Name and Occupation

Who all lives at home?

Does your child attend daycare?

Yes

Any family/social situations we should be aware of (ex: DHS involvement, family separation)

Is your child up to date on immunizations? *

Yes

Has your child ever had an allergic reaction to previous immunizations? *

Yes

Does your child have any underlying medical conditions? If yes, please describe. Examples: eczema, asthma, heart problems, seizures, ear infections.

Does your child have any underlying psychological conditions? If yes, please describe. Examples: anxiety, depression, ADHD

Are there any medical problems that run in the family? If yes, please describe. Examples: cancer, diabetes, heart disease, high blood pressure.

Parent/Guardian Signature

Today's Date

Thank you. Your registration was successfully submitted.

503-255-1432

Monday - Friday 9:00 am - 5:00 pm
Saturday 9:00 am - 3:00 pm
Sunday Closed

Northern

Pediatrics

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