Get Pediatric Client Intake Form 2016-2025

Filling out the Pediatric Client Intake Form online is a crucial step in ensuring your child receives appropriate care. This comprehensive guide provides clear instructions to help you navigate the form with confidence and ease.

Follow the steps to complete the form efficiently.

1. Click ‘Get Form’ button to access the Pediatric Client Intake Form and open it in a digital editing format.
2. Begin by entering the patient's information, including their name, preferred name (if applicable), address, city/state, zip code, and county. Ensure that you include the main and any alternate phone numbers, date of birth, and gender.
3. Provide the social security number, birth state, preferred language, housing status (homeless or not), and complete the ethnicity and race sections as applicable.
4. Next, fill in the parent or guardian information. Specify their relationship to the patient, and enter their contact numbers, email address, and preferred method of contact. If applicable, also complete the fields for the family size and total household income.
5. Identify the primary caregiver by filling in their name, relationship to the patient, and phone number. Specify if they are the same as the parent or guardian.
6. Provide information for the healthcare proxy, if appointed, including their name, relationship, and contact details.
7. Enter emergency contact information for someone who does not live with the child. Make sure to note their relationship to the child and confirm whether they are aware of the child's patient status.
8. In the medical information section, specify the name and address of the primary care provider and preferred pharmacy, along with their phone numbers.
9. Answer the insurance questions thoroughly. Indicate whether anyone in your household has coverage and provide specifics if applicable, including the type of coverage.
10. Assess and record any significant medical history, including serious illnesses, accidents, surgeries, hospitalizations, allergies, and any developmental concerns.
11. Review and answer additional questions regarding family medical history and any concerns about your child’s health.
12. Complete the consent and acknowledgment sections, ensuring to initial and sign where required, confirming your understanding of the information and your consent.
13. Once all fields are completed, save the document to your device. You can also download, print, or share the completed form as needed.

Take an important step for your child's health by completing the Pediatric Client Intake Form online today.