Welcome to Prospect Pediatrics PA

At Prospect Pediatrics, we provide excellent health care for our patients from infancy through age 21years, in a child friendly relaxed atmosphere designed to make children and family members feel at home and safe. There is continuity of care of your child - the same doctor sees your child each visit.

MISSION STATEMENT:
At Prospect Pediatrics, Our goal is to provide an exceptional quality, comprehensive healthcare for our patients in a compassionate and respectful manner. We pledge to take care of the whole child in the context of his/her family, school and community in the highest ethical and professional level. We take that commitment serious . We feel privileged to be part of your child's life.

-At prospect Pediatrics, we listen while you talk
-Every question that you care about is important to us.
-We provide personalized care
-We simply care.

PATIENT REGISTRATION

Child's Last Name:
First Name:
Cellphone:
Email Address:
MI:
Name Child Likes to be Called:
Gender :
Date of Birth:
Additional Children:
Name Child Likes to be Called:
Mailing (Billing ) Address*
Street or Post Box:
City:
State:
Zip Code:
Primary Language Spoken in the Home:

Contact Numbers / Emails

Patients Primary Phone:
Cell Phone:

Parent 1:

Name:
Date of Birth:
Work Phone:
Cell Phone:
Personal E-mail:
Work Email:
Employer:
Lives with patient? (Check one):
 Yes No
Relationship to Patient:

Parent 2:

Name:
Date of Birth:
Work Phone:
Cell Phone:
Personal E-mail:
Work Email:
Employer:
Lives with patient? (Check one):
 Yes No
Relationship to Patient:

Emergency Contact (other than parents): Name and Relationship

1:
Phone:
2:
Phone:
3:
Phone:
4:
Phone:

Insurance

Primary Insurance:

Policy Holder's Last Name:
First Name:
MI:
Policy Holder's Date of Birth:
ID#:
Group #:

Secondary Insurance:

Policy Holder's Last Name:
First Name:
MI:
Policy Holder's Date of Birth:
ID#:
Group #:

Billing Statements Sent To (if different from above):

Name:

Relationship to Patient:

Address:

Primary Phone:

Cell Phone:

Privacy Constrains (check one):

 No Restrictions Restrictions Person Restrictions

If parents are divorced separated, please fill put this section:

Who has custody?

Are there any legal restrictions that would restrict the non-custodial
parent from consenting to medical treatment for the
child or from obtaining information about the child's medical treatments?

 Yes No

If yes, please explain and provide a copy of any legal paperwork that supports this restrictions.
 
I authjorize the release of any medical or other information necessary to process claims from
Prospect Pediatrics PA. I also request payment of government benefits either to myself or to
the party who accept assingment below.
 
Signature:

Date:


Address
163 Belleville Avenue Belleville, NJ 07109

Telephone
973-302-4644

Fax
973.528.2242