AutoRemind

1.

Patient first name*

Patient last name*

Patient dob*

2.

Patient first name*

Patient last name*

Patient DOB*

3.

Patient first name*

Patient last name*

Patient DOB*

Ethnicity

Unknown

Hispanic or Latino

Not Hispanic or Latino

Declined to specify

Race

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Who does patient(s) live with?:

Mom

Dad

Legal Guardian

Other

Other, who?*

Mom's information

Name*

DOB*

Phone*

Address*

Email*

Dad’s Information:

Dad Name*

DOB*

Phone*

Address*

Email*

OR Legal guardian Information (if applicable) *please provide custody paperwork and photo ID*

Name*

DOB*

Phone*

Address*

Email*

custody paperwork and photo ID *

If it doesn't apply you can type n/a

May we leave a message on voicemail with results?

Yes

No

May we send you a text messages?

Yes

No

Insurance Information

Primary insurance name*

Primary insured*

Primary insured DOB*

Primary Members ID*

Primary Group Number*

Secondary insurance information

Secondary Insured Name*

Secondary Insured*

Secondary Insured DOB*

Member ID*

Group Number*

Patient Update

custody paperwork and photo ID *

E-Signature