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JCS PEDIATRICS REGISTRATION FORM (Please Print) Today s date: PCP: JORGE W. BLACK, MD PATIENT INFORMATION Patient s last name: First: Middle: Marital status (circle one) Single / Mar / Div / Sep /

How to fill out jks pediatrics registration form

How to fill out jks pediatrics registration form:

1. Start by filling out the personal information section. This includes your full name, date of birth, gender, and contact details. Make sure to provide accurate information.
2. Next, fill out the medical history section. This involves answering questions about any previous medical conditions, allergies, surgeries, medications, and ongoing treatments.
3. Proceed to provide information about your child's immunization records. Include the dates of immunizations and the vaccines received.
4. If your child has any specific healthcare needs or conditions, there may be a section to document these details. Provide complete and accurate information to ensure proper care is provided.
5. Some registration forms may ask for information about your child's primary care physician or any other healthcare professionals involved in their care. Include their names, contact information, and any relevant details.
6. The form may require you to provide insurance information. Include the name of the insurance company, policy number, and any additional details requested.
7. Don't forget to review the form before submitting it. Ensure all the required fields are filled out correctly and that you haven't missed any important information.
8. Finally, sign and date the form to indicate your consent and understanding of the provided information.

Who needs jks pediatrics registration form:

1. New patients: Any new patient seeking care from JKS Pediatrics would need to fill out the registration form. This helps the healthcare providers gather important information about the patient's medical history and other necessary details.
2. Existing patients: Even if you are an existing patient of JKS Pediatrics, there may be instances where you need to update your information or provide additional details. In such cases, you would be required to fill out the registration form again.
3. Siblings of existing patients: If you have another child who needs care from JKS Pediatrics and they are not already registered, they would need to fill out the registration form. This ensures that all the necessary information is available for proper healthcare management.

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