REGISTRATION FORM

Children’s Admitting Department
1935 Medical District Dr
Dallas, TX 75235
Please fax to: 214-456-2197
Questions? Call 214-456-2190

My child is coming to Children's Medical Center Dallas on (date) / / @ (time) _________AM ________PM

For (circle one): Inpatient Admission Day Surgery Outpatient Specialist Visit (What specialty?)___________________

This admission/appointment was scheduled by Dr. (physician’s name)_______________________________________________

Patient’s LEGAL Name (LAST)__________________________ (FIRST)______________________ (MIDDLE)_________________

Preferred Name ______________________________________

Mother’s Maiden Name ________________________________

Address ___________________________________________

City/State/ZIP _______________________________________

County Hm # ( )

Male Female Birthdate

Patient’s SS# Race

Religious Preference

Language Preferred: English Spanish Other __________

Are the patient’s immunizations current? YES NO

(*Name of Physician ,Hospital, or other Medical Provider who sent you to Children’s for THIS admission)

Referred By

Address ___________________________________________

Office Ph # _________________________________________

City/State/ZIP ________________________________________

Office Fax # ________________________________________

Was your child transported to Children’s by ambulance, helicopter, or airplane? (Please circle) YES NO
(If yes, please include hospital name on the “Referred By” line above.)

(*Name of Physician or other Medical Provider who usually treats your child)

PCP (Primary Care Physician)

Address ___________________________________________

Office Ph # _________________________________________

City/State/ZIP ________________________________________

Office Fax # ________________________________________

(*Name of person responsible for the bill. NOTE: If parents are divorced, the parent who brings the child in for treatment is the Guarantor.)

Guarantor	Relation to Patient	Employer Name
Address	Birthdate	Address
City/State/Zip	SS#	City/State/Zip
Hm #	Cell #	Wk #
Email Address	Pager #	Occupation

Other Parent	Relation to Patient	Employer Name
Address	Birthdate	Address
City/State/Zip	SS#	City/State/Zip
Hm #	Cell #	Wk #
Email Address	Pager #	Occupation

Next of Kin Name

Relation to Patient

Address

Employer

City/State/Zip

Wk #

Hm #

Cell #

Pager #

Emergency Contact Name

Relation to Patient

Address

Employer

City/State/Zip

Wk #

Hm #

Cell #

Pager #

(*Deductibles/Copays are due at the time of your visit/admission unless other arrangements are made with a Financial Counselor.)

Primary Insurance ___________________________________

Address ___________________________________________

Subscriber Name ___________ _____________________

Policy/ SS#

Group Name & Group #

Type of Plan? HMO POS PPO EPO Other

City/State/ZIP _______________________________________

Relation to Patient___________ _____________________

Benefits/Eligibility Ph #

Precert or Authorization Ph #

Secondary Insurance _________________________________

Address ___________________________________________

Subscriber Name ___________ _____________________

Policy/ SS#

Group Name & Group #

Type of Plan? HMO POS PPO EPO Other

City/State/ZIP _______________________________________

Relation to Patient___________ _____________________

Benefits/Eligibility Ph #

Precert or Authorization Ph #

Children's Medical Center Dallas must document your preference for publicity (i.e. receiving visitors, phone calls, flowers, mail, etc. from persons outside the hospital, including family members and friends). Please indicate your preference for this indicator by checking one of the statements listed below.

NOTE: We cannot acknowledge your child’s admission to SOME people while excluding it from others. The publicity indicator is EITHER all inclusive (meaning, information can/will be release to ALL persons) OR all exclusive (meaning, information can/will be released to NO ONE.)

I DO wish for Children’s Medical Center Dallas to acknowledge my child’s presence at the hospital as outlined above.

I DO NOT wish for Children’s Medical Center Dallas to acknowledge my child’s presence at the hospital as outlined above.

FOR HOSPITAL USE ONLY: IP OBSV DSU: DA DS 1DWU STP OP: Clinic

MR#

ACCT#

Expected Arrival/Pre-Surgical Assessment Date / / Admit/Surgery Date / /

Entered By On / /