New Patient Form — Grace Pediatrics | Lake City & Fort White, FL

1

Child's Information

▼

First Name *

Middle Name

Last Name *

Suffix

Date of Birth *

Sex *

Social Security #

Email

Preferred Language

Ethnicity

Race

Address

Street Address *

City *

State *

Zip *

Preferences

Child's Pharmacy

Preferred Office Location

Preferred Provider

How did you hear about us?

2

Parent / Guardian Information

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Mother / Guardian 1

First Name *

Last Name *

Middle Name

Relationship to Child *

Date of Birth

SS #

Address (if different from child)

City

State / Zip

Home Phone

Cell Phone *

Work Phone

Place of Employment

Race

Ethnicity

Father / Guardian 2

First Name

Last Name

Middle Name

Relationship to Child

Date of Birth

SS #

Address (if different from child)

City

State / Zip

Home Phone

Cell Phone

Work Phone

Place of Employment

Race

Ethnicity

Child lives with:

If other, please specify:

3

Emergency Contacts & Authorized Persons

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Emergency Contact

Name *

Relationship to Child *

Phone *

Persons Authorized to Bring Child to Appointments

List anyone other than the parents/guardians above who are authorized to accompany your child to office visits and consent to examination, diagnostic testing, immunization, and/or treatment.

Full Name	Relationship to Child	Phone Number

4

Insurance Information

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Primary Insurance

Insurance Company *

Member / ID Number

Group Number

Name of Insured (Subscriber)

Relationship to Patient

Secondary Insurance (if applicable)

Insurance Company

Member / ID Number

Group Number

Name of Insured (Subscriber)

Relationship to Patient

5

Pregnancy & Birth History

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Birth Weight

Birth Length

Delivery Type

Hospital where child was born

Date baby went home

Birth Complications

Mother treated for infection during pregnancy?

Yes No

Infant treated for infection?

Yes No

Antibiotics given to mother?

Yes No

Antibiotics given to infant?

Yes No

Jaundice?

Yes No

Low birth weight?

Yes No

Prematurity?

Yes No

Any other trouble at birth?

Yes No

Please explain any "Yes" answers above:

Mother's History

Age at time of birth

Total # of pregnancies

Total # of live births

Smoke during pregnancy?

Yes No

Drink during pregnancy?

Yes No

Drugs during pregnancy?

Yes No

6

Medical History

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Allergies

Does your child have any known allergies? *

Yes No

Current Medications

Is your child currently taking any medications?

Yes No

Past Medical History

Check any conditions your child has been diagnosed with:

If other, please describe:

Surgical Procedures

List all surgical procedures your child has had and the year they were performed:

Year	Procedure

Family Medical History

Does anyone in the immediate family (parents, siblings, grandparents) have a history of:

Please describe any family history noted above:

7

Nutrition, Dental & Vision

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Nutritional Assessment

For Newborns / Infants:

Feeding method

If formula, which one?

How many ounces per feeding?

Started cereal?

Yes No

Started juices?

Yes No

Started solid foods?

Yes No

For Toddlers / All Patients:

Any food allergies?

Yes No

Any feeding / eating concerns?

Yes No

If yes, please describe:

Dental

Has child seen a dentist? (if over 3)

Yes No

Does child brush teeth?

Yes No

Fluoride in water supply?

Yes No

Vision & Hearing

Any concerns with child's vision or hearing?

Yes No

Has child been evaluated by an eye doctor?

Yes No

8

School & Development

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School name (if school-aged)

Current grade

Any concerns about your child's growth or development?

Yes No

Has your child been told they are developmentally delayed?

Yes No

If yes, please explain:

9

Social History

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Has this child been exposed to any of the following?

Secondhand smoke

Yes No

Alcohol / Drugs

Yes No

Physical abuse

Yes No

Mental / Emotional abuse

Yes No

Sexual abuse

Yes No

Tuberculosis

Yes No

HIV / AIDS

Yes No

Other exposures:

Household Information

Who all lives with child?

Primary language in household

If not English, can you provide an interpreter?

Yes No N/A

10

Additional Information

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Previous pediatrician / doctor's name and practice

Reason for leaving previous provider (optional)

Any other issues you would like to discuss with the provider?

11

Consent & Signature

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Parent / Guardian Printed Name *

Date *

Type your full name below as your electronic signature:

Parent / Guardian Signature

✅ ELECTRONICALLY SIGNED

By signing electronically, I agree that my electronic signature is the legal equivalent of my handwritten signature, valid per FL Statute § 668.50 (UETA) & 15 U.S.C. § 7001(a) (ESIGN Act). I certify that all information provided is accurate to the best of my knowledge. Photo ID required at first visit.

Relationship to Patient *

12

Assignment of Benefits & Financial Policy

▼

I have read and understand the above *

Yes, I have read and agree to the above terms

Parent / Guardian Printed Name

Signature (type full name)

✅ ELECTRONICALLY SIGNED

By signing electronically, I agree that my electronic signature is the legal equivalent of my handwritten signature, valid per FL Statute § 668.50 (UETA) & 15 U.S.C. § 7001(a) (ESIGN Act). Photo ID required at first visit.

Date

13

Acknowledgement of Privacy Practices (HIPAA)

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Print Name

Signature (type full name)

✅ ELECTRONICALLY SIGNED

By signing electronically, I agree that my electronic signature is the legal equivalent of my handwritten signature, valid per FL Statute § 668.50 (UETA) & 15 U.S.C. § 7001(a) (ESIGN Act). Photo ID required at first visit.

Date

14

Vaccine Policy

▼

I have read and understand the above *

Yes, I have read and understand the vaccine policy

Signature (type full name)

✅ ELECTRONICALLY SIGNED

By signing electronically, I agree that my electronic signature is the legal equivalent of my handwritten signature, valid per FL Statute § 668.50 (UETA) & 15 U.S.C. § 7001(a) (ESIGN Act). Photo ID required at first visit.

Date

15

Photo & Image Consent

▼

Photo & image consent

I consent to medical photographs and patient portal images I do not consent

Child's Name

Parent Signature (type full name)

✅ ELECTRONICALLY SIGNED

By signing electronically, I agree that my electronic signature is the legal equivalent of my handwritten signature, valid per FL Statute § 668.50 (UETA) & 15 U.S.C. § 7001(a) (ESIGN Act). Photo ID required at first visit.

Date

16

Medical Records Release

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Information May Be Disclosed BY (Previous Provider)

Person / Facility Name

Phone #

Address

City

State

Zip

Information May Be Disclosed TO

Person / Facility

Phone #

Method of Disclosure

Fax #: 386-438-5945 Email Address (please note that emailing may not be a secured method of communication)

Information to Be Disclosed

Select the types of records to be released:

Other (specify):

Special Authorization

I specifically authorize release of information relating to: (initial selection)

HIV test results Substance Abuse Service Provider Client Records Psychiatric, Psychological or Psychotherapeutic notes Early Intervention WIC

Purpose of Disclosure

Continuity of Care Personal Use Other (specify):

Expiration & Legal Notices

Expiration Date: If no expiration date is specified, this authorization will expire twelve (12) months from the date on which it was signed.

Client / Legal Representative Signature *

✅ ELECTRONICALLY SIGNED

By signing electronically, I agree that my electronic signature is the legal equivalent of my handwritten signature, valid per FL Statute § 668.50 (UETA) & 15 U.S.C. § 7001(a) (ESIGN Act). I certify that all information provided is accurate to the best of my knowledge. Photo ID required at first visit.

Date

Printed Name

Legal Representative's Relationship to Client

Patient Name

DOB

If you are a legal representative of the person whose information you are requesting, you must provide documentation proving your legal authority to the request (for example, power of attorney, healthcare surrogate form, order, appointment of a guardianship, order appointing personal representative, letters of administration).

New Patient Registration

Child's Information

Parent / Guardian Information

Mother / Guardian 1

Father / Guardian 2

Emergency Contacts & Authorized Persons

Insurance Information

Primary Insurance

Secondary Insurance (if applicable)

Pregnancy & Birth History

Medical History

Nutrition, Dental & Vision

School & Development

Social History

Additional Information

Consent & Signature

Assignment of Benefits & Financial Policy

Acknowledgement of Privacy Practices (HIPAA)

Vaccine Policy

Photo & Image Consent

Medical Records Release

AUTHORIZATION TO DISCLOSE CONFIDENTIAL INFORMATION