Demographic Form Name of Person Completing Form *Parent's Email Address *Parent's Phone *How did you hear about us? Patient's InformationPatients Full Legal Name *Date of Birth *Patients Social Security # Patients Address (Address, City, State, Zip) Patients Home Phone *Gender *MaleFemalePhysician InformationName of Child's Regular Doctor *Physician's Address (Address, City, State, Zip) *Physician's Phone *Parent/Legal Guardian #1Parent Legal Guardian #1 Name *Parent Legal Guardian #1 Relationship to Patient Parent Legal Guardian #1 Gender Parent Legal Guardian #1 Date of Birth *Parent Legal Guardian #1 Social Security # *Parent Legal Guardian #1 Address (Address, City, State, Zip) *PhoneParent Legal Guardian #1 Home Phone *Parent Legal Guardian #1 Work Phone Parent Legal Guardian #1 Cell Phone Parent Legal Guardian #1 Name of Employment Parent Legal Guardian #1 Address of Emplyment (Address, City, State, Zip) Parent Legal Guardian #1 Employment Status Parent Legal Guardian #1 Occupation Parent/Legal Guardian #2Parent Legal Guardian #2 Name Parent Legal Guardian #2 Relationship to Patient Parent Legal Guardian #2 Gender Parent Legal Guardian #2 Date of Birth Parent Legal Guardian #2 Social Security Parent Legal Guardian #2 Address (Address, City, State, Zip) Parent Legal Guardian #2 Home Phone Parent Legal Guardian #2 Work Phone Parent Legal Guardian #2 Cell Phone Parent Legal Guardian #2 Place of Employment Parent Legal Guardian #2 Address of Employment (Address, City, State, Zip) Parent Legal Guardian #2 Employment Status Parent Legal Guardian #2 Occupation Emergency ContactEmergency Contact Name *Emergency Contact Relationship to Patient *Emergency Contact Phone # *Primary Insurance InformationPrimary Insurance Company Name *Primary Insurance Phone # *Primary Insurance Address (Address, City, State, Zip) *Name of Insured (Primary Insurance) *Primary Insured Date of Birth *Relationship to Patient (Primary Insurance) *Insurance Policy or Member ID # (as shown on card including any alpha characters) *Group# (Primary Insurance) *Primary Insured's Social Security Number Secondary InsuranceSecondary Insurance Company Secondary Insurance Phone Secondary Insurance Address (Address, City, State, Zip) Name of Insured (Secondary Insurance) Relationship to Patient (Secondary Insurance) Insurance Policy ID or Subscriber # (Secondary Insurance) Primary Subscriber Social Security # (Secondary Insurance) VerificationPlease enter any two digits with no spaces (Example: 12) *This box is for spam protection - please leave it blank: