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Alpine Pediatrics, P.C. Family Information (For All Patients) Please Use Full Legal Names Fathers Name: Date of Birth: Social Security #: Mothers Name: Date of Birth: Social Security#: Street Address:

How to fill out alpine pediatrics p

How to fill out Alpine Pediatrics P:

1. Start by gathering all the necessary information and documents required for the form, such as personal details, medical history, and insurance information.
2. Begin filling out the form by providing your full name, date of birth, and contact information in the designated fields.
3. Proceed by answering the questions related to your medical history. Be thorough and accurate, providing information about any existing conditions, allergies, medications, or surgeries.
4. If applicable, provide your insurance information, including your policy number and primary care physician.
5. Make sure to read and understand each question before answering. If you have any doubts or need clarification, don't hesitate to ask the staff at Alpine Pediatrics for assistance.
6. Once you have completed all the required sections, review the form to ensure all the information provided is correct and legible.
7. Sign and date the form at the bottom to certify its accuracy and completeness.
8. Keep a copy of the filled-out form for your records before submitting it to Alpine Pediatrics.

Who needs Alpine Pediatrics P:

1. Parents or guardians who want to enroll their child at Alpine Pediatrics as their primary healthcare provider.
2. Individuals seeking pediatric medical care or services for children aged from infancy to adolescence.
3. Patients who wish to have their medical records transferred to Alpine Pediatrics for continued care and management.

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