New Patient Forms New Patient Forms The CMS (Centers for Medicare & Medicaid Services) and the American Academy of Pediatrics have respectively required and recommended all the patient forms. All insurance companies are requiring us to have these completed for reimbursement. We apologize for any inconvenience this causes. New Patient(s) Consent to Treat (Select Appropriate Clinic) For which clinic is this form? * logo acf-forms activecampaign authorize aweber bootstrap campaignmonitor constant_contact getresponse googlesheets highrise hubspot mailchimp mailpoet paypal icon polylang salesforce salesforcealt stripe stripealt twilio woocommerce Zapier required delete move drag clear noclear duplicate copy clone tooltip tooltip_solid forbid checkmark image checkmark circle checkmark square check check1 plus plus1 plus2 plus3 plus4 minus minus1 minus2 minus3 minus4 cancel cancel1 close report_problem_solid report_problem arrowup arrowup1 arrowup2 arrowup3 arrowup4 arrowup5 arrowup5_solid arrowup7 arrowup6 arrowup8 arrowdown arrowdown1 arrowdown2 arrowdown3 arrowdown4 arrowdown5 arrowdown5_solid arrowdown7 arrowdown6 arrow_left arrow_right filter download upload2 download2 hard_drive pencil_solid pencil signature register account_circle_solid account_circle address_card paragraph checkbox_unchecked checkbox checkbox_solid dropdown caret_square_down radio_unchecked scrubber location_solid location toggle_on toggle_off shield_check shield_check_solid clock clock_solid email_solid mail_bulk code tag tag_solid price_tags search sitemap file file_text_solid file_text option option_solid more_horiz more_vert more_horiz_solid more_vert_solid calculator key key Filled Key Icon keyboard eye eye_solid eye_slash_solid page_break view_day attach_file printer header h1 repeat repeater save sliders code_commit star star_full star_half linear_scale pie_chart stats_bars sms feed align_right align_left button browser cloud_upload_solid shuffle swap pallet fingerprint ghost heart_solid heart history import export label_solid label lock_open lock alt_lock dollar_sign percent notification external_link pageview_solid pageview settings stamp support text white_label building icontact sendinblue sendy wordpress credit_card credit_card_alt cc_amex cc_discover cc_mastercard cc_visa cc_paypal icon cc_stripe price product total quantity directory Preview Storybook Pediatrics G. F. Still ADHD Clinic Date * (MM/DD/YYYY) Children's Names * Parent(s) Names * All Person(s), including parents, who have permission to obtain medical care for my children: * I (we), the legal quardians of the above named children do hereby give my(our) consent for the persons listed below to obtain medical care for my (our) children at Storybook Pediatrics. I (we) understand that by giving persons permission to take my child/children to Storybook Pediatrics for medical care, I am also giving Storybook Pediatrics permission to disclose my child's (children's) protected health information to any of the persons on this list. I also understand that by giving these persons permision to take my child (children) to Storybook Pediatrics for medical care that I am also giving these persons my permission to make medical care decisions for my child (children) during those visits. Parent or Legal Guardian Signature: * I (we) agree to this medical consent Signature * signature keyboard Clear Guarantee of Payment Storybook Pediatrics requires a credit, debit, or health savings card on file. Providing quality healthcare to our patients and good service to their parents is very costly. Adequate cash flow is critical to the financial viability of this practice; therefore, parents must provide a concrete guarantee of payment for services. I agree to place a credit, debit, or Health Savings Account card on file in my guarantor record. I understand that only the last four numbers of the card are visible to any employees who might have access to my guarantor record. I understand that after the processing of insurance claims is complete that I will be billed via email for any remaining amounts that are deemed patient responsibility and that the balance is due within 14 days of billing. Should payment not be received by this office within the 14 days subsequent to billing, I understand that the credit/debit card placed on file will be run to pay the balance. I understand that should the amount of the balance be problematic to pay within the 14 day window that it will be my responsibility to call the billing office and arrange a payment plan. I understand that MY CARD WILL NEVER BE CHARGED UNLESS I FAIL TO PAY MY ACCOUNT BALANCE WITHIN THE TIME LIMIT STATED ABOVE. * I (we) agree to place a card on file when requested Signature * signature keyboard Clear Attendance Policy In order to be fair to all of our patients, patients must arrive on time for their appointments in order to be seen by a nurse or provider. If a patient arrives late and there is room in the schedule, we will accommodate the patient by moving him/her into a later schedule slot. If there is no room in the schedule, you will be asked to reschedule. All appointments must be cancelled 24 hours in advance in order to avoid a $50 missed appointment fee. Appointments may be cancelled by calling our office during regular hours or emailing care@ronsmithmd.com outside of our regular office hours. * I (we) agree to the attendance policy Signature * signature keyboard Clear Interim History Update Child's Name * DOB * (MM/DD/YYYY) Street * City * State * Zip * Current Contact Information Mom's Name Mom's Phone Mom's Relationship Biologic Adoptive Mom's Email Confirm Mom's Email Email verification Stepmother's Name Stepmother's Phone Stepmother's Email Confirm Stepmother's Email Email verification Father's Name Father's Phone Father's Relationship Biologic Adoptive Father's Email Confirm Father's Email Email verification Stepfather's Name Stepfather's Phone Stepfather's Email Confirm Stepfather's Email Email verification Legal Guardian Name Legal Guardian Phone Legal Guardian Email Confirm Legal Guardian Email Email verification Insurance Company Member ID If there are any changes in parent's or grandparents' health which you do not want to discuss in front of your child, then please elaborate. Interim Medical History arrowup6 1. Surgeries or Procedures (including endoscopy, EKG, dental work, etc) since last well check 2. Dates and reasons for overnight hospitalizations since last well check 3. Name, specialty, and date seen for any specialist visit since last well check Current Prescription Oral Medications arrowup6 1. Oral medication 1. Dose 2. Oral medication 2. Dose 3. Other Oral Meds/Doses Current Prescription Topical Medications (creams, etc.) arrowup6 1. Topical medication 1. Dose 2. Topical medication 2. Dose 3. Other Topical Meds/Doses Current Prescription Inhaled Medications arrowup6 1. Inhaled medication 1. Dose 2. Inhaled medication 2. Dose 3. Other Inhaled Meds/Doses Current Over-the-Counter Medications arrowup6 1. Medication 1. Dose 2. Medication 2. Dose 3. Other Meds/Doses Allergies arrowup6 1. Medication 2. Medication 1. Food 2. Food 3. Other Allergies Environmental Primary water source (for children under six) Well water City water Bottled water Does this child (if under age three) live in or frequently visit a house constructed before 1978? Yes No Section Parent or Legal Guardian Signature signature keyboard Clear Child's Name * DOB High blood pressure Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings High Cholesterol or Triglycerides Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Heart Attack Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother Siblings List ages as ordered as above.List ages as ordered as above. Stroke Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother Siblings List ages as ordered above.List ages as ordered above. Type II Diabetes Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Hypothyroid (low thyroid) Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Lupus Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Rheumatoid arthritis Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Celiac Disease Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Crohn’s Disease Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Ulcerative Colitis Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Type I Diabetes Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Other Autoimmune Disorders Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Free Bleeder Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Clotting Disorder Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Irritable Bowel Syndrome Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Autism Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Developmental Delay Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Speech Disorder Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Intellectual Disability Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Learning Disability Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings ADHD/ADD Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Anxiety Disorder Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Depression Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Mental Illness Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Food allergies Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Asthma Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Hypertrophic cardiomyopathy Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Wolf Parkinson White Syndrome Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Prolonged QT Syndrome Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Deafness Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Vision Problems Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Seizure disorder Mom Dad Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother SiblingsSiblings Who lives in the household with your child Please list all people who reside in the household. Any other family history you feel it is important for your provider to know: If parents are divorced or not married, what is the custody arrangement? Are any of the child’s parents, grandparents, or siblings deceased? If so, which is/are deceased? Please list cause of death. Are any of the child’s parents’, grandparents’, or siblings’ medical history unknown? If so please list which relation’s history is unknown. Submit If you are human, leave this field blank.
