Patient's Full Name_______________________________Phone#_______________
                    Last       First      Middle 
Nickname_______________________________________________________________

Birthdate_______/_______/_______Sex M or F  PatientSS#_____-_____-_____

Father's Name ______________________________________Phone#_____________
                    Last         First        Middle 
Father's Address_______________________________________________________
                Number and Street (No P.O. Boxes)    City   St  Zipcode

Father's SS#_____-_____-_____Father's Date of Birth______/______/______

Father's Employer ___________________________________Phone#____________

Mother's Name ______________________________________Phone#_____________
                        Last         First        Middle              

Mother's Address_______________________________________________________
                Number and Street (No P.O. Boxes)    City   St  Zipcode

Mother's SS#_____-_____-_____ Mother's Date ofBirth_____/______/_______

Mother's Employer __________________________________Phone#_____________

Legal Gaurdian of Child   _____________________________________________

Stepmother / Father in Home   _________________________________________

Social Worker's Name (if applicable)_________________Phone#____________ 

If Covered by Kentucky Medical Assistance Card. We must have a copy of 
your card before your child is seen by the physician, or you will be 
required to pay the first visit in full.

Please list two emergency contacts that live outside of the home.

Name___________________________Relation______________Phone#____________

Address________________________________________________________________
                Number and Street (No P.O. Boxes)    City   St  Zipcode

Name___________________________Relation______________Phone#____________

Address________________________________________________________________
                Number and Street (No P.O. Boxes)    City   St  Zipcode

Primary Insurance Company______________________________________________

Address  ______________________________________________________________
                Number and Street (No P.O. Boxes)    City   St  Zipcode

I.D. Number_________________________________Group Number_______________

Insured's Name_______________________Relation to Patient_______________

Date of Birth______________________________SS#_________________________

Insured's Employer_________________________Eff. Date___________________

I authorize Prospect Pediatrics to initiate and maintain medical/surg-
ical treatment of my child/children in an emergency or life threat-
ening situation until proper notification can be given and consent ob-
tained.  

I authorize release of medical or other information acquired during the
course of examination and treatment to insurance carriers.   I hereby
request payment benefits to Prospect Pediatrics.  I understand I am re-
sponsible for any amount not covered by insurance.

Signature____________________________________________Date______________

Child's previous or existing conditions:

Medication Allergies__________________________________________________

Birth Weight______________________________Birth Length________________

Complications at Birth________________________________________________

Convulsions___________________________________________________________

Diabetes______________________________________________________________

Heart Disease / Defects_______________________________________________

Asthma________________________________________________________________

Tonsillectomy / Tubes / ENT Problems _________________________________

______________________________________________________________________

Childhood Diseases____________________________________________________

Chronic or Repeated Illnesses_________________________________________

Any Other Pertinent History___________________________________________

______________________________________________________________________

List all Medications that the child is currently taking or has taken 
on a regular basis.

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

List Family Members with a History of:

Heart Disease_________________________________________________________

Birth Defects_________________________________________________________

Anemia________________________________________________________________

Kidney Disease________________________________________________________

Tuberculosis__________________________________________________________

Epilepsy______________________________________________________________