NEW PATIENT CHILD INTAKE FORM

Please complete all sections of your New Patient Forms and return them within 72 hours before your appointment.

Child Name

First Name

Last Name

Date of Birth

YYYY

Gender

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

Country

(###)

###

####

Name Parent / Guardian Information

First Name

Last Name

Policyholder Name

First Name

Last Name

Relationship

Insurance Information

Insurance Company Nme

Insurance ID#

Policyholder Date of Birth

YYYY

Medical History

Pediatrician/ Primary Care Provider

Medications

As part of your health history, please let us know if you have any allergies, including to food, medications, or other substances

Chronic Conditions (Check all that apply)

Checkbox

Diabetes

Poor appetite

Picky eating

Digestive problems (constipation, diarrhea, bloating)

Concerns about weight gain or loss

Family history of obesity, diabetes, heart disease, or high cholesterol

Reason for Visit / Please describe any other concerns about your child’s nutrition, eating behavior, or health:

Please provide your current height and weight to help us better understand your nutritional and health needs:

What is your child height ?

What is your child weight ?

****Please note that cancellations made less than 48 hours before your appointment will incur a $50.00 fee. We appreciate your understanding, as this allows us to manage our schedule and serve all patients efficiently.

****Patient Information Accuracy & Responsibility.I, the undersigned, acknowledge that the information I have provided on this form is complete and accurate to the best of my knowledge. I understand that: It is my responsibility to provide correct and up-to-date information, including medical history, insurance details, and contact information. If any information is inaccurate or incomplete, I may be responsible for any resulting fees, charges, or denied claims.

****By signing below, I confirm that all information is correct and accept responsibility for any costs arising from incorrect or missing information.

Signature

Date

YYYY