Patient
Registration Form Howard
G. Smith, M.D. Pediatric
Ear, Nose & Throat Associates
65 LaSalle Road -- Suite 219
West Hartford Center, Connecticut 06107 Voice:
860-236-3277 • Fax: 860-232-2750
Please
fill out the form below and print a hard copy to
bring with you to your first visit.
Alternatively, you may fax us a copy at
860-232-2750. Please be certain to bring your
child's insurance card to the first visit.
At the present time, this form generator will
operate properly with Safari, Firefox, and
Internet Explorer.
CHILD’S NAME:
First:MI:Last:
Nickname: Date
of Birth:
Gender:
Child’s Social Security #:
provide only the last 4 digits
Child’s Home Address:
City:
State: Zip:
Home Phone:
Family Cell Phone: for
Family email address:
Referred by:
Primary Physician:
POLICYHOLDER'S NAME:
Social Security #:
(last 4 digits) Date of
Birth:
Home Address:
City:
State: Zip:
Home Phone: Cell
Phone:
Occupation:
Employer:
Employer’s Address:
City:
State: Zip:
Work Phone: May
we contact you at work?
OTHER PARENT’S NAME:
Social Security #: (last
4 digits) Date of
Birth:
Home Address:
City:
State: Zip:
Home Phone: Cell
Phone:
Occupation:
Employer:
Employer's Address:
City:
State: Zip:
Work Phone: May
we contact you at work?
PHARMACY INFORMATION
Pharmacy #1:
Name:
Address:
City: Zip:
Phone:
Fax:
CHILD’S PRIMARY INSURANCE
Company:
Plan Name:
Policy Holder: Co-pay amount:
ID#:
Group#:
Address:
Phone Number:
Is a referral required for specialist visit?
CHILD'S SECONDARY INSURANCE
Company:
Plan Name:
Policy Holder: Co-pay amount:
ID#:
Group#:
Address:
Phone Number:
Is a referral required for specialist visit?
Thank
you for taking the time to complete this form.
We are looking forward to meeting you at your
child's first visit.
Back
to