PEDIATRIC REGISTRATION FORM Please Print MALE FEMALE

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Transcription:

PEDIATRIC REGISTRATION FORM Please Print MALE FEMALE Name Birth / / LAST FIRST MI Address City State Zip Home Phone ( ) Parent s Work ( ) Social Security # Parent s Cell ( ) Email Address Parent s Marital Status: Married Divorced Widow Never Married Referred By PERSON RESPONSIBLE FOR PAYMENT: Name Relationship DOB Employed By Social Security # Insurance Policy No. PERSONS TO CONTACT IN CASE OF EMERGENCY Name Phone # ( ) Name Phone # ( ) CANCELLATION/RESCHEDULE POLICY: IF YOU NEED TO CANCEL OR RESCHEDULE YOUR APPOINTMENT, PLEASE NOTIFY OUR OFFICE 3 BUSINESS PRIOR, OR YOUR ACCOUNT WILL BE CHARGED THE FULL AMOUNT OF YOUR APPOINTMENT. PAYMENT IS DUE AT TIME OF VISIT BY EITHER CASH, CHECK, OR CREDIT CARD. WE REQUIRE that you or others accompanying you NOT wear colognes, perfumes, scents, or scented lotions the day of your child s visit. We keep a scent free office for people with chemical sensitivities. Please sign and return at least one week prior to your child s appointment. WE WILL NEED BOTH PARENTS CONSENT. I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE THE ABOVE INFORMATION IS CORRECT. I UNDERSTAND THE CANCELLATION POLICY AND PAYMENT POLICY. I HEREBY CONSENT TO MEDICAL AND HOMEOPATHIC TREATMENT BY JEFF D. LESTER, D.O. SIGNATURE SIGNATURE DATE DATE

PEDIATRIC INFORMATION Name Last First MI Name commonly called (if different from above) CURRENT PROBLEMS 4. 5. PAST PROBLEMS of Onset FURTHER DESCRIPTIONS OF PROBLEMS SURGERIES OR HOSPITALIZATIONS MEDICATIONS: Dose

Name PEDIATRIC INFORMATION Last First MI LIVING SITUATION Members at Home NAME AGE RELATIONSHIP 4. 5. SIBLINGS NOT LIVING AT HOME NAME AGE PETS AT HOME 4. ALLERGIES (Medications, Foods, Environment) SUBSTANCE REACTION BIRHT HISTORY Place of Birth Birth Weight Weeks Gestation Maternal Problems During Pregnancy Problems During Labor

PEDIATRIC INFORMATION Name Last First MI Number of Months Breastfed: IMMUNIZATIONS (Please bring your Immunization card) Immunizations Given: (Circle one) All on Time Delayed None Significant vaccine reactions, if any: Has the child had any of these problems? Trouble Sleeping Nightmares Frequent Ear Infections Headaches Speech Impediment Frequent Sore Throats Asthma Whooping Cough Gastric Reflux Frequent Stomach aches Constipation Bed Wetting (Over 4 years Old) Discharge from Genitals Excessive Weight Loss Excessive Weight Gain Additional Comments or Special Problems (Please check) Excess Body Heat Eczema Psoriasis Warts Serious Accident Shyness Fears Overly Clingy Temper Fits Breaks or Throws things Fighting Lying Nervous Habits Family Problems Vision Impaired Family Medical History Describe significant illnesses of family members or symptoms that tend to run through your heritage, including mental/emotional (ie. Arthritis, Cancer, Heart disease, Depression).

HEAD, EYES, NOSE & THROAT: RESPIRATORY: CARDIOVASCULAR: GASTROINTESTINAL: (Any Scoping with s) RECTAL TROUBLE: (Constipation, Diarrhea, Anal Itching, Fissures, Hemorrhoids) URINATION: DERMATOLOGICAL: (Rashes, Sweat, Acne Treatments) SPINE & EXTREMITIES: (Specify Neck or Back Abnormalities i.e. Cramping, Pain or Numbness) SLEEP:

DREAMS: (Recurrent Themes) ENERGY: (When Low & High) TEMPERATURE: (Generally feel warm or chilly) TIME OF DAY PROBLEMS OCCUR: OTHER:

E-MAIL AGREEMENT Trilogy Medical, Inc. Jeff D. Lester, D.O. 280 W Hamilton Ave Campbell, CA 95008 Phone (408) 844-0010 Fax (669) 300-6912 info@trilogymedical.net E-Mail is a welcome way to consult with our office regarding problems and questions. No emergency material is to be communicated by e-mail. For Doctor to read e-mails: $40.00 ½ page $60.00 Full page There is no charge for the staff to receive e-mails regarding setting up an appointment or sending remedies. REMEDY BY MAIL Homeopathic remedies can be sent to you by mail, by the following procedures; Call or e-mail with which remedy or remedies are needed ie: daily dose, booster dose(lm1) or high dose. Include your credit card number if not already on file. For efficiency please arrange to have your credit card on file (your number will be protected). Shipping and Handling is $8.00. Credit Card Number (Visa, Mastercard, American Express Accepted). Please include your expiration date: I understand & agree with the above policies

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