Riverside Pediatrics Patient Registration Form

PATIENT INFORMATION
PARENT/GUARDIAN INFORMATION

Parent/Guardian 1 Information

Contact Preference:



Parent/Guardian 2 Information

Contact Preference:



INSURANCE INFORMATION
SIBLINGS INFORMATION
Brothers and Sisters:
Siblings' Names and Dates of Birth
FOR ALL CHILDREN
Can we obtain medication history from your pharmacy?:

Consent to call *: in person/automated?:

Consent to Text *: you may receive texts from the office?:

Has the Notice of Privacy Practices been made available to you? *:

BIRTH AND DEVELOPMENT HISTORY
RACE, ETHNICITY AND PRIMARY LANGUAGE

The Federal Government requires medical practices to collect the following information. There is a provision in the law that allows patients to not answer these questions. Please answer the following three questions or select the "I decline to provide this information" answer.

1. My ethnicity is (please check one answer):

2. My race is (please check one answer):





2. My preferred language is:


Optional:
AUTHORIZATION FOR TREATMENT
Permissions:
Who else has permission to bring this child to Riverside Pediatrics and authorize treatment?
SIGNATURE
Now(UTC - 07:00)
Enter security code:
 Security code
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FIND US

843-833-8595

435 Marina Drive
Georgetown, SC 29440

Directions

Office Hours

MONDAY – FRIDAY
8:00 AM – 5:00 PM
SATURDAY
8:00 AM – 10:00 AM

843-401-4200

402 Nelson Boulevard
Kingstree, SC 29556

Directions

Office Hours

MON, WED, THUR, FRI
8:00 AM – 5:00 PM
TUESDAY
8:30 AM - 5:00 PM
SATURDAY
Closed

RECOGNITIONS

American Board of Pediatrics American Academy of Pediatrics NCQA Patient-Centered Medical Home
Copyright © 2024 Riverside Pediatrics. All rights reserved.
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