New Patient Registration


Child's Name: Date of Birth:
      mm/dd/yy
Gender: Male Female Child's Social Security #
Street Address:
City, State, Zip Code:
Telephone:  
  Primary Alternative
       

Parent/ Guardian Demographics

Father’s Name: Mother’s Name:
Date of Birth: Date of Birth:
Social Security #: Social Security #:
Employer Name: Employer Name:
Work Phone: Work Phone:
Cell Phone: Cell Phone:
Email: Email:
Pharmacy Name/ #:    
       
Do any siblings come to our office?: YES NO    
Who Referred you to us: The Motherhood Center Houston Baby The Bump Exp Mothers Guide Other
       
Emergency Contact Name: Phone:
       

Assignment of Insurance Benefits

I hereby authorize direct payment of surgical/ medical benefits to Dr. Virginia Araiza, PLLC, for services rendered by her in person or under her supervision. I understand that I am financially responsible for any balance not covered by my insurance. Any services rendered outside of the clinic, i.e.: lab work, blood tests, x-rays, etc., that are not covered by insurance will be my financial responsibility.
       

Authorization to Release Information

I hereby authorize Dr. Virginia Araiza, PLLC, to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit.
       
 
Patient Name   Date
       
 
Parent / Guardian Name   Parent / Guardian Email
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Pediatric services are available to all children; office visit fees can be billed to medical insurance or paid in cash.
A sliding schedule of fees for uninsured children is available. Contact us now for more information.
The information contained in this website is to provide information of a general nature about the
practice and pediatric medical conditions. Neither Dr. Leonhardt nor Bee Well Pediatrics, P.A. is engaged in rendering medical
advice or recommendations. You should always consult your doctor for advice.