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.

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

Add a second parent / guardian (optional)

Parent / Guardian #2

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.

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