Get Uptown Pediatrics

Filling out the Uptown Pediatrics patient information sheet online is a straightforward process designed to gather essential information about your child and their healthcare needs. This guide will provide clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the Uptown Pediatrics patient information sheet

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. Enter the date at the top of the form to document when the information is being submitted.
3. Fill in the patient’s first and last name, along with their date of birth in the appropriate fields.
4. Provide the name of the hospital where the patient was born and select the appropriate gender option by checking either male or female.
5. If the patient is a newborn, indicate the child’s last name while in the hospital in the designated field.
6. Specify how you heard about Uptown Pediatrics by filling in the textbox provided.
7. Indicate whether you had your prenatal visit with Uptown Pediatrics by selecting yes or no.
8. Input the mother's name and date of birth in the respective fields.
9. Enter the father's name and date of birth in the required fields.
10. Provide the complete home address of the patient, along with a home telephone number.
11. Enter the email address for contact purposes.
12. Specify who the patient lives with by selecting the appropriate option and providing more information if necessary.
13. If the address is different from the home address provided, enter it in the section specified.
14. Fill in the cell and work phone numbers for both mother and father.
15. List an emergency contact other than the parents, including their phone number and relationship to the patient.
16. Enter the telephone number for the pharmacy you regularly use.
17. In the insurance information section, provide details about the primary insurance plan, including plan name, policy number, group number, and the policy holder's name and date of birth.
18. Indicate the relationship of the primary policy holder to the patient and their employer.
19. Provide the name and relationship to the patient of the responsible bill payer (guarantor) and obtain their signature and date.
20. Ensure a copy of the insurance card is brought to the receptionist and review the financial policy for any additional information.
21. Once all fields are filled in accurately, save your changes, and download, print, or share the form as needed.

Complete your documents online today for a streamlined experience.