Patient Registration and Patient Agreement with MVP Pediatric and Urgent Care - For Established Patients

Demographic Information

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50% of survey complete.

Please complete the following information, so that we can expedite your registration. Thank you!

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 / Time

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 / Time

Date

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* 7. Gender

Male

Female

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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)?

Yes, please see changes below

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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

Same as above

Other (please specify)

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

Same as above

Other (please specify)

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* 21. Emergency Contact

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* 22. Emergency Contact Phone Number

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* 23. Preferred Language

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* 24. Ethnicity

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* 25. Race

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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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* 29. How did you hear about us?