Follow the steps to complete the intake form effortlessly.

1. Click the ‘Get Form’ button to access the Pediatric Patient Intake Form and open it for editing.
2. Enter the patient's legal name, date of birth, last four digits of the social security number, and gender. Ensure that personal details are accurately filled in.
3. Provide the patient's address, including city, state, and zip code, along with home and cell phone numbers. An email address is also required.
4. Indicate the patient’s occupation or grade and the employer or school information. Choose the preferred language, race, and ethnicity for more specific data collection.
5. Fill out the information for the parent or guardian, including their name, relationship to the patient, and date of birth. If there are multiple guardians, repeat the process for additional entries.
6. Detail how the patient found the eyecare group and provide referral information if applicable. This may include the name and phone number of the referring provider.
7. Enter insurance details, including the vision and medical insurance company names, subscriber’s names and IDs, and the relationship to the subscriber. Make sure all insurance information is correct for verification.
8. Review the authorization statement, ensuring all necessary sections are completed and signatures are obtained before proceeding. This includes acknowledging the HIPAA Privacy Act.
9. Complete the health history section, including the patient’s last eye exam, medical doctor details, medications, allergies, and any developmental delays or therapies that may be relevant.
10. For the personal eye health history, answer the yes/no questions regarding eye conditions and previous injuries, ensuring to mark with clear indicators.
11. Fill out social history, including alcohol and tobacco usage to provide a comprehensive health overview.
12. Finally, review all sections of the form. Once satisfied, you can save changes, download, print, or share the form, ensuring that you have a copy for personal records.

Complete your Pediatric Patient Intake Form online today to facilitate smooth processing at your appointment.