2727 Gramercy St.
Suite #225
Houston, TX 77025
Phone: 713-665-4567
Fax: 713-665-8962
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Medical Information

Patient Registration Form OP Version 8



This is a "secure" form. To ensure the privacy of your personal information, all data provided on this form is encrypted for transmission between your computer and our web server.

If you would like to print a complete set of patient registration forms and bring them with you to your appointment, please click here Complete Patient Registration Forms

For your convenience, all children who share the same parent(s) or legal guardian(s) and are covered by the same insurance plan can be entered at the same time. If these factors are not the same for any of your children, you must submit a separate form for them.

If your child has already been seen at VIP Pediatrics, DO NOT USE this form. Please go to the Patient Login tab at the top middle of all pages.


Please Note: This form is designed for pre-registration of a new family to our practice. It currently can not be used to add a new family member to an established family. If your family is already registered with our practice, please register any new family members directly with the office.

In cases of divorce and/or remarriage, please provide information for the adult(s) who have legal custody (the authority to make medical decisions on the child's behalf), with the person who most often has physical custody listed first. You will have an opportunity to provide contact information for other interested adults, such as step-parents, when you visit the office.

Parent/Guardian Information

   
Parent/guardian 1 (most frequent contact for healthcare issues)
Relationship:    should always be checked
Name (first, MI, last):    
Address:  
City/state/zip code:
Home phone:
Work phone: Ext:
Cell phone:
Home Email Addr:
Work Email Addr:
Preferred method of communication.
Medical: Reminder: Recall: Billing:
Parent/guardian 2 (leave address/phone blank if same as above)
Relationship:   
Name (first, MI, last):
Address:
City/state/zip code:
Home phone:
Work phone: Ext:
Cell phone:
Home Email Addr:
Work Email Addr:
Preferred method of communication.
Medical: Reminder: Recall: Billing:
Insurance information
Insurance company:

 

Group number:
Provided through
parent/guardian:		   1                           2                           Other
Patient (child) information
If you are expecting a child, please enter "BABY" as the first name, along with an approximate due date.
       
First name MI Last name Sex Birth/due date Insurance ID

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