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CHILDREN HEART CLINIC 411 N. Central Ave., Suite 250 Glendale, CA 91203 P: 818.839.7101 × F: 818.839.7199 www.TheChildrensHeartClinic.comHISTORY QUESTIONNAIRE (AGE 421) Patient Name:___Date of Birth:___Primary
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Obtain the necessary forms from Harbor Pediatric Medical Group or download them from their website.
02
Fill out the patient's personal information, including name, date of birth, address, and insurance information.
03
Provide the child's medical history, including any allergies, current medications, and previous illnesses.
04
Sign any consent forms required by the medical group.
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Submit the completed forms to Harbor Pediatric Medical Group either in person or electronically.

Who needs harbor pediatric medical group?

01
Parents or guardians of children in need of pediatric medical care
02
Children in need of primary care services from a pediatrician
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Harbor Pediatric Medical Group is a medical group specializing in pediatric care.
Harbor Pediatric Medical Group is typically filed by healthcare providers or medical practices specializing in pediatrics.
To fill out Harbor Pediatric Medical Group, healthcare providers must report specific information relating to their pediatric medical practice.
The purpose of Harbor Pediatric Medical Group is to track and monitor the healthcare services provided to pediatric patients.
Information reported on Harbor Pediatric Medical Group may include patient demographics, medical history, treatments provided, and outcomes.
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