HEIGHTS PEDIATRICS
Dr. Katerina Silverblatt, Dr. Alexandra McCollum, Emily Zgorski, CPNP
718-858-4924
www.heightspediatrics.com
Patients Full Name: __________________________________________
Female □ Male □ Date of Birth: _____/____/____
Address: __________________________________________________
City:__________________ State:____________ Zip Code:___________
Home Phone: (_____)_____-_______ Cell Phone:(_____)______-_______
E-mail Address: _____________________________________________
Parents Name: ____________________ Date of Birth:____/____/_____
Cell Phone: (____)_____-_________ Work Phone:(_____)_____-_______
Social Security: _____-_____-_____
Parents Name: ____________________ Date of Birth:____/____/_____
Cell Phone: (____)_____-_________ Work Phone:(_____)_____-_______
Social Security: _____-_____-_____
Emergency Contact:_________________ Phone: (_____)______-_______
Insurance Carrier: _________________________ Copay: $___________
Member ID: _______________________ Group#:__________________
Address/P.O. Box#:__________________________________________
Policy Holder: _____________________ Social Security:____-____-____
Relationship to Patient:________________________________________
OPTIONAL: Heights Pediatrics is authorized to maintain credit card payment information in our confidential files. Your signature authorizes us to review the information and deduct copayments and fees from the credit card below, when you sign application. We do not take AMERICAN EXPRESS or DISCOVER. At this time we do take VISA or MASTERCARD.
Mastercard □ Visa □
Cardholder Name (as appears on Credit Card): ______________________
Cardholder Signature: ________________________________________
Credit/Debit Card Number: _ _ _ _ - _ _ _ _ - _ _ _ _-_ _ _ _
Expiration Date: _______________________ V-Code:_______________
Mailing Address: ____________________________________________
*DID YOUR CHILD RECEIVE HEP B IN THE HOSPITAL □Yes □ No
*Please provide copy of immunization records and insurance card*
Newborn Lab ID (pink slip received in hospital – 9 Digits) ______________
Parent’s Signature: _________________________ Date: ____________
Reviewed and entered by Staff Member: ___________