Pediatric

Registration

To complete this form, you will need the following information and / or documentation:

➞ Patient Demographics (including social security number)
➞ Medical, Dental, and / or Vision Insurance card(s)
➞ Parent or Guardian (demographics | social security number | identification card or driver’s license | authorization for medical treatment of minor, if anyone other than parent with legal custody is completing form)
➞ Tribal identification, if applicable

Please ensure you have all appropriate documents ready prior to completing forms. If your screen is left idle for more than one hour, the system will automatically close, and your forms will not be saved.

Pediatric Registration

"*" indicates required fields

Are you interested in obtaining services for Children's Behavioral Health?

Yes

Patient Demographics

Name*

First Last

Name

Middle

Preferred Name

Preferred Pronouns

Assigned Sex at Birth*

Gender Identity*

Date of Birth*

Social Security Number*

Refusing to provide a patient and / or policyholder's social security number can cause delays in your insurance company processing claims. If your insurance company is unable to remit payment for services rendered because they cannot confirm your identity, you will be responsible for all charges.

Are you a member of an American Indian or Alaska Native Tribe or descendant of an enrolled member of an American Indian or Alaska Native?*

If Yes, Name of Tribe*

Upload Tribal Documentation*

Max. file size: 10 MB.

If you do not have your tribal documentation, please select No, and bring to your first appointment. Staff will update once documentation is provided.

Mailing Address*

Street Address City State ZIP Code

Primary Phone*

May We Leave a Message?*

Yes

Email Address*

When did you move to current community?*

Current county*

Place of Birth*

City State

Can you access internet?*

Yes

Secondary phone number

Religious preference

Father's Name*

First Last

Father's Employer

Father's Employer Phone

Mother's Name*

First Last

Mother's Employer

Mother's Employer Phone

Emergency Contact 01

Other than Parent

Name*

First Last

Address*

Street Address City State ZIP Code

Emergency Contact 01

Primary Phone*

Emergency Contact 01

Relationship to Patient*

Emergency Contact 01

Add Another Emergency Contact?*

Emergency Contact 02

Other than Parent

Name*

First Last

Address*

Street Address City State ZIP Code

Emergency Contact 02

Primary Phone*

Emergency Contact 02

Relationship to Patient*

Emergency Contact 02

Patient Information

Are you employed?

Yes

Employer Name

Employer Phone

Ethnicity*

Race*

American Indian / Alaska Native

Asian

Black / African American

Native Hawaiian or Other Pacific Islander

White

Decline to Answer

Other

Number in Household*

Total Number in Household*

Do you have an Identification card or driver’s license?*

N/A

Yes

ID or Driver's License Upload*

Max. file size: 10 MB.

Next of Kin Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Relationship to Patient*

Patient Information Cont.

Preferred Language*

Do you need an interpreter?*

Yes

Do You Have Health Insurance?*

Health Insurance Information

Which Health Insurance Services Do You Have?*

Medical (Complete Below Form)

Dental (Complete Below Form)

Vision (No Form to Complete)

Uninsured / Cash Pay

Select All that Apply

Primary Medical Insurance

Do You Have Medical Insurance Card to Upload?*

If you do not have an insurance card to upload prior to your appointment, please fill out insurance details and bring insurance card(s) to your first appointment. As a reminder, without proper insurance verification, you can be held responsible for any financial charges accrued.

Insurance Card Upload (Medical)*

Max. file size: 10 MB.

Insurance Co. Name (Medical)*

Insurance Co. Address (Medical)*

Street Address City State ZIP Code

Insurance Co. Phone (Medical)*

Member No. (Medical)*

Group No. (Medical)*

Last Name (Medical)*

Policyholder’s Information

First Name (Medical)*

Policyholder’s Information

Middle Name (Medical)

Policyholder’s Information

Legal Sex (Medical)*

Policyholder’s Information

Date of Birth (Medical)*

Policyholder’s Information

Do You Have Other Medical Insurance?*

Other Medical Insurance

Do You Have Other Medical Insurance Card to Upload?*

Insurance Card Upload (Other Medical)*

Max. file size: 10 MB.

Insurance Co. Name (Other Medical)*

Insurance Co. Address (Other Medical)*

Street Address City State ZIP Code

Insurance Co. Phone (Other Medical)*

Member No. (Other Medical)*

Group No. (Other Medical)*

Last Name (Other Medical)*

Policyholder’s Information

First Name (Other Medical)*

Policyholder’s Information

Middle Name (Other Medical)

Policyholder’s Information

Legal Sex (Other Medical)*

Policyholder’s Information

Date of Birth (Other Medical)*

Policyholder’s Information

Primary Dental Insurance

Do You Have Dental Insurance Card to Upload?*

Insurance Card Upload (Dental)*

Max. file size: 10 MB.

Insurance Co. Name (Dental)*

Insurance Co. Address (Dental)*

Street Address City State ZIP Code

Insurance Co. Phone (Dental)*

Member No. (Dental)*

Group No. (Dental)*

Last Name (Dental)*

Policyholder’s Information

First Name (Dental)*

Policyholder’s Information

Middle Name (Dental)

Policyholder’s Information

Legal Sex (Dental)*

Policyholder’s Information

Date of Birth (Dental)*

Policyholder’s Information

Do You Have Other Dental Insurance?*

Other Dental Insurance

Do You Have Other Dental Insurance Card to Upload?*

Insurance Card Upload (Other Dental)*

Max. file size: 10 MB.

Insurance Co. Name (Other Dental)*

Insurance Co. Address (Other Dental)*

Street Address City State ZIP Code

Insurance Co. Phone (Other Dental)*

Member No. (Other Dental)*

Group No. (Other Dental)*

Last Name (Other Dental)*

Policyholder’s Information

First Name (Other Dental)*

Policyholder’s Information

Middle Name (Other Dental)

Policyholder’s Information

Legal Sex (Other Dental)*

Policyholder’s Information

Date of Birth (Other Dental)*

Policyholder’s Information

Move On to Parent / Guardian Section*

Click Here

Parent or Guardian

Last Name*

Parent or Guardian

First Name*

Parent or Guardian

Middle

Parent or Guardian

Suffix

Parent or Guardian

Gender Identity*

Parent or Guardian

Primary Phone No.*

Parent or Guardian

May We Leave a Message?*

Yes

Secondary Phone No.

Parent or Guardian

May We Leave a Message?

Yes

Do You Have Same Address as the Patient?*

Address*

Street Address City State ZIP Code

Parent or Guardian

Email Address

Parent or Guardian

Relationship to Patient*

Parent with Legal Custody

Legal Guardian

Foster Out-Of-Home Care

Parent or Guardian

Upload Legal Documentation*

Max. file size: 10 MB.

Parent or Guardian

EXAMPLES: Court order signed by Judge, or letter from Child Support Services, or Licensed Foster Agency

DISCLAIMER: Without proper legal documentation that indicates you have authorization to seek medical treatment for the minor patient, you cannot complete this form.

Marital Status*

Parent or Guardian

Ethnicity*

Parent or Guardian

Race*

American Indian / Alaska Native

Asian

Black / African American

Native Hawaiian or Other Pacific Islander

White

Decline to Answer

Other

Parent or Guardian

ID Card Upload*

Max. file size: 10 MB.

Parent or Guardian

Preferred Language

Parent or Guardian

If Other than English

Do You Need an Interpreter?*

Yes

Parent or Guardian

Move On to Household Questionnaire*

Click Here

Parent or Guardian

Household Questionnaire

Are you a Migrant Agricultural Worker?

Yes

Are You Currently Homeless / Unhoused?

Yes

Do You Have Access to the Internet?

Yes

Total Household Income

Per Year

Move Onto Signatures Section*

Click Here

Patient Signatures

Release of Information Signature*

Release of information, the Shingle Springs Health & Wellness Center has permission to release information needed for insurance processing to my insurance.

Today's Date*

Release of Information

I Certify the Information Provided is True and Accurate.*

Today's Date*

True and Accurate Certification

Pediatric

Registration

To complete this form, you will need the following information and / or documentation:

Pediatric Registration

Patient Demographics

Emergency Contact 01

Emergency Contact 02

Patient Information

Next of Kin Information

Patient Information Cont.

Health Insurance Information

Primary Medical Insurance

Other Medical Insurance

Primary Dental Insurance

Other Dental Insurance

Parent or Guardian

Household Questionnaire

Patient Signatures

Contact Us

Careers

Patient Information

Behavioral Health

Children’s Behavioral Health

Dental

Medical

Pediatrics

Pharmacy

PRC & Specialty Care

Pediatric

Registration

To complete this form, you will need the following information and / or documentation:

Pediatric Registration

Patient Demographics

Emergency Contact 01

Emergency Contact 02

Patient Information

Next of Kin Information

Patient Information Cont.

Health Insurance Information

Primary Medical Insurance

Other Medical Insurance

Primary Dental Insurance

Other Dental Insurance

Parent or Guardian

Household Questionnaire

Patient Signatures

Behavioral Health

Suicide & Crisis Lifeline

Crisis Hotline Center: 9-8-8

Children's Behavioral Health

Dental Services

Orthodontic Services

Medical

PEDIATRICS

Pharmacy Services

Drug Take Back Program

SPECIALTY CARE SERVICES

ACUPUNCTURE

CHIROPRACTIC

PHYSICAL THERAPY

PODIATRY