Pediatric Clinic de Chino Hills
                      15944 Los Serranos Country Club Dr. Suite 160, Chino Hills, CA 91709
                                              Tel: (909) 606-8893; Fax: (909) 606-8828

                                               PATIENT REGISTRATION FORM

Patient information:

Last Name_________________ First Name ______________ Middle INT _____ Birth Date _____________
Address: # & Street _____________________________ City_______________ State ____ Zip _________
Home Phone ____________ Cell Phone ____________ Sex (Male/Female) _______ SSN _____________
School Name (optional) _______________________ Preferred Pharmacy
___________________________
Reason for visit ____________________________ Primary Care Doctor/City ______________________
Drug Allergies _________________________ Current Medications
________________________________
Parent(s)/Legal Guardian Information (Responsible Party) & Contact:
Legal Guardian’s Name ____________________________ SSN ___________ Birth Date ____________
Relationship_______________ Work Phone ____________________ Cell Phone____________________
Address _______________________________________ Employer ______________________________
Emergent Contact Person _____________________ Contact phone_____________
Relationship_________
Address _______________________________________
Employer_______________________________
Insurance Information:
Primary Coverage___________________ Group# ___________________ Plan# ____________________
Subscriber’s Name___________________________ Birth Date ____________ Effective Date __________
Subscriber's Address ______________________________________________ Co-Payment ___________
Secondary Coverage ___________________ Group#__________________ Plan# ___________________
Insured’s Name______________________________ Birth Date ____________ Effective Date __________
Subscriber's Address ______________________________________________ Co-Payment ___________

I, being the patient or parent/legal guardian of the patient, certify that the above information is true to the best of
my knowledge.  I hereby give my consent for tests, procedures, and treatments of  me/my dependent to Doctor
HUA BAI, MD.  I understand that the co-payment/deductibles shall be paid at the time of each visit, and
authorize direct payment of my insurance benefits for covered services to Doctor HUA BAI, MD.  I also
understand that any balance not covered by my insurance will be my full responsibility.  I acknowledge that I
have been provided the Notice of Privacy Practices of PCCH.  I also authorize Doctor HUA BAI, MD and/or the
insurance company to release any information required to process my claim. I further authorize the release of
the patient’s private health information to other providers involved his/her care. I intend this agreement to cover
this visit and any future care for which I or my dependents seek.  

Name (Print) _______________________________ Signature __________________ Date ____________
_______________________________________________________________________________________________
                                                       PCCH OFFICE USE ONLY

Verify ID Type: ______Driver’s License/Passport_________ Employee Signature: _____________ Date: ____________
Patient Registration Form --- English