11/01/2025 Well Child and Sports Physical Clinic at Esquire Elementary 9 am - 3pm

PCHS Demographic Information (One Survey per patient)

This survey is to reserve an appointment slot for each individual patient. Please be prepared to fill out a full registration form upon arrival.

Question Title

* 1. Patient Last Name

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* 2. Patient First Name

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* 3. Patient Date of Birth

Date of Birth

Date

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* 4. Patient Sex at Birth

Male

Female

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* 5. Address

Address *

City/Town *

State/Province *

ZIP/Postal Code *

Email Address

Phone Number *

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* 6. Consent to Call

Yes

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* 7. Text Message ok?

Yes

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* 8. Insurance

Primary Insurance Name

ID Number

Guarantor (person who is responsible for the insurance) Name and Date of Birth

Insurance mailing address for claims (address on back of card, not your address)

Secondary Insurance Name

ID Number

Guarantor (person who is responsible for the insurance) Name and Date of Birth

Insurance mailing address for claims (address on back of card, not your address)

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* 9. If uninsured and you would like to be contacted about how to apply for slide scale or insurance, please check the box.

Contact me about Slide Scale or to set up an appointment with an insurance navigator

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* 10. Billing Authorization
Please read the statements below. Check each box (last box for Medicare recipients only)
Enter your name and date to provide authorization.

I accept financial responsibility for all my professional services and/or supplies. Payment for service is due at the time rendered unless arrangements have been made.

I authorize my insurance to pay PCHS directly. I am financially responsible for any balance due. I authorize PCHS or the insurance company to release any information for claims unless specifically limited by me in writing.

(Medicare Recipients Only) I request that payment for authorized Medicare benefits be made on behalf of Peninsula Community Health Services for any services provided to me

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* 11. Full Name of Parent or Guardian

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* 12. Date

Date / Time

Date

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* 13. Select the box below if you would like to receive a copy of the Patient Rights and Responsibilities

Mail me a copy of the Rights and Responsibilities

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* 14. Confirm you have filled out the forms listed below (Forms are required for appointment)

English Forms

Formas Españolas

I have printed and filled out forms

11/01/2025 Well Child and Sports Physical Clinic at Esquire Elementary 9 am - 3pm

PCHS Demographic Information (One Survey per patient)

Question Title

* 1. Patient Last Name

Question Title

* 2. Patient First Name

Question Title

* 3. Patient Date of Birth

Question Title

* 4. Patient Sex at Birth

Question Title

* 5. Address

Question Title

* 6. Consent to Call

Question Title

* 7. Text Message ok?

Question Title

* 8. Insurance

Question Title

* 9. If uninsured and you would like to be contacted about how to apply for slide scale or insurance, please check the box.

Question Title

* 10. Billing AuthorizationPlease read the statements below. Check each box (last box for Medicare recipients only)Enter your name and date to provide authorization.

Question Title

* 11. Full Name of Parent or Guardian

Question Title

* 12. Date

Question Title

* 13. Select the box below if you would like to receive a copy of the Patient Rights and Responsibilities

Question Title

* 14. Confirm you have filled out the forms listed below (Forms are required for appointment)English FormsFormas Españolas

* 10. Billing Authorization
Please read the statements below. Check each box (last box for Medicare recipients only)
Enter your name and date to provide authorization.

* 14. Confirm you have filled out the forms listed below (Forms are required for appointment)

English Forms

Formas Españolas