Demographic Information

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I voluntarily present to MVP Pediatric and Urgent Care and consent to treatment by the physician on duty and whomever they may designate as their assistant, associate, treating physician and patient care staff to provide my child’s care or myself (if I am the patient and older than 18 years of age). Such care may include, but is not limited to, diagnostic procedures, radiological evaluations and procedures, and the administration of medications considered advisable in my child’s or my diagnosis, treatment, and course of care. I acknowledge that no guarantee can be made or has been made as to the results of treatments or examinations and I understand that all medical treatments contain inherent risks

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* 1. Date of Urgent Care Visit

Date

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* 2. Reason for visit:

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* 3. Patient Last Name

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* 4. Patient First Name

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* 5. Patient Middle Initial

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* 6. Patient Date of Birth

Date

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* 7. Gender

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* 8. Have there been any changes to the following demographic information, since you last visit (if there are no changes, you can continue to the next page)?

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* 9. Primary Street Address

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* 10. City

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* 11. State

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* 12. Zip Code

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* 13. Country

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* 14. Primary Phone Number

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* 15. Day Phone Number

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* 16. Mobile Phone Number

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* 17. Email Address

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* 18. Parent(s)/Guardian(s) Name(s)

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* 19. Parent(s)/Guardian(s) Address

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* 20. Parent(s)/Guardian(s) Phone Number

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* 21. Emergency Contact

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* 22. Emergency Contact Phone Number

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* 26. Name of Primary Pediatrician or Primary Care Physician

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* 27. Primary Pediatrician or Primary Care Physician Address

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* 28. Primary Pediatrician or Primary Care Physician Phone Number

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