Get Pocket Patient App Applicant

Filling out the Pocket Patient App Applicant form is an essential step in the process of seeking medical care for your child. This guide provides a clear and structured approach to help you complete the form accurately and efficiently.

Follow the steps to complete the application successfully.

1. Press the ‘Get Form’ button to access the application and open it in your editor.
2. Indicate whether the child has been a patient at Texas Scottish Rite Hospital for Children by checking 'Yes' or 'No'. If 'Yes', provide the year and medical record number (MR#) if available.
3. Enter the child’s name as it appears on their birth certificate, along with their date of birth and age. Check the box to select the gender.
4. If you have a religious preference, you may provide that information in the designated section.
5. Indicate if the child speaks English by checking 'Yes' or 'No'. If 'No', write the child's primary language.
6. Fill in the child’s address, social security number, and home phone number. If there is no social security number, enter 'none'.
7. Provide details about the child's biological or adoptive parents, including names, addresses, and contact information. Indicate their marital status.
8. Include information about the father's and mother's employers, job titles, and primary languages. If applicable, check the boxes regarding any hearing or speech impairments.
9. Designate a relative or friend who can be contacted in case of an emergency by providing their name, relationship to the child, and contact details.
10. If applicable, detail any legal custody arrangements by including the relevant court order information and the names of managing conservators.
11. Indicate if the child does not live with the parents or managing conservators, and provide the name and address where appointment information should be sent.
12. List any siblings or other family members who are or have been patients at Texas Scottish Rite Hospital for Children, along with their birth dates and medical record numbers.
13. Review and complete the agreement and acknowledgment section to grant permission for medical evaluation and treatment.
14. Ensure that the application is signed by the parents or managing conservators, including the date of signature.
15. After reviewing the completed application, save any changes, download the form, or share it as needed before submitting it to the hospital.

Complete your application online today to begin the process of securing medical care for your child.