Ansari Pediatrics

Which office will you visit?

Your completed forms are sent to that location's front desk.

Parent / Guardian information

Enter this once — it applies to every child you register today.

⌨️Please type names and addresses using your English (Latin) keyboard. Accents and letters from many languages are supported, but some non-Latin alphabets may not print correctly on your forms.

Parent / Guardian #1 required

First name *

Last name *

Date of birth

Home address *

Apt

City *

Zip *

Cell phone *

Home phone

Work phone

Email

Relationship to children

SSN

Employer

Occupation

This child has only one parent / guardian — second parent's information is not available

Parent / Guardian #2 required

First name *

Last name *

Date of birth

Address (if different)

Apt

City

Zip

Cell phone

Home phone

Work phone

Email

Relationship to children *

SSN

Employer

Occupation

Emergency contact

Name

Relationship

Phone

Upload a photo of your ID (optional)

Parent / Guardian ID

Your children

Add each child being registered. Shared parent, address, policy and signature details are reused automatically — you only enter what's specific to each child.

⌨️Please enter each child's name using your English (Latin) keyboard so it prints correctly on the forms.

Office policies

Please read each policy and confirm. Enter your initials once — they apply to all sections and all children.

Your initials *

Signature

This signature applies to the insurance assignment, financial responsibility, records authorization, and HIPAA Notice of Privacy Practices — for every child registered today.

Signed by (print name) *

Date *

Sign below *

Draw with finger or mouse

Which office will you visit?

Parent / Guardian information

Your children

Office policies

Signature

Review

Child