Serenity Pediatrics Registration Part 2 of 2
Please make sure that you have completed Part 1 of the registration form
Email address *
Patient Name (Last Name Required) *
Your answer
Patient date of Birth (or due date) *
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YYYY
Contact Name and Relationship to patient *
Your answer
Contact Phone Number *
Your answer
Primary Insurance
Primary Ins Company name
Your answer
Primary Ins: Full Name of Enrollee/Subscriber (Policy Holder)
Your answer
Primary Ins: Phone # of Enrollee/Subscriber (Policy Holder)
Your answer
Primary Ins: Relationship to Patient
Your answer
Primary Ins: Enrollee/Subscriber's Date of Birth
MM
/
DD
/
YYYY
Primary Ins: Enrollee ID
Your answer
Primary Ins: Group Number
Your answer
Primary Ins: Employer Name
Your answer
2nd Insurance
Secondary Insurance Company name
Your answer
Secondary Ins: Full Name of Enrollee/Subscriber (Policy Holder)
Your answer
Secondary Ins: Reationship to Patient
Your answer
Secondary Ins: Enrollee/Subscriber's Date of Birth
MM
/
DD
/
YYYY
Secondary Ins: Enrollee ID
Your answer
Secondary Ins: Group Number
Your answer
3rd Insurance
Is your visit related to Injury (Auto / Work Comp / Liability)?
Tertiary Ins: Company name
Your answer
Tertiary Ins: Full Name of Enrollee/Subscriber (Policy Holder)
Your answer
Tertiary Ins: Reationship to Patient
Your answer
Tertiary Ins: Enrollee/Subscriber's Date of Birth
MM
/
DD
/
YYYY
Tertiary Ins: Enrollee ID
Your answer
Tertiary Ins: Group Number
Your answer
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