# New Patient Registration Form

## Patient Information
- **Patient Name:** _________________________
- **Date of Birth:** _________________________
- **Gender:** ☐ Male ☐ Female ☐ Other
- **Social Security Number:** _________________________

## Contact Information
- **Address:** _________________________
- **City:** _________________________ **State:** _________ **ZIP:** _________
- **Phone:** _________________________
- **Email:** _________________________

## Emergency Contact
- **Name:** _________________________
- **Relationship:** _________________________
- **Phone:** _________________________

## Insurance Information
- **Primary Insurance:** _________________________
- **Policy Number:** _________________________
- **Group Number:** _________________________
- **Secondary Insurance:** _________________________

## Consent & Authorization
☐ I consent to medical treatment for my child
☐ I authorize billing to my insurance company
☐ I consent to receive appointment reminders
☐ I acknowledge receipt of HIPAA Notice

**Parent/Guardian Signature:** _________________________
**Date:** _________________________

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*Rose Pediatrics Care - New Patient Registration Form*