Patient Demographics

Please fill out this form as completely as possible. It will be sent securely to our office.

You will be asked to provide photos of the front and back of your insurance card(s), as well as the front of your driver’s license or state ID.

Patient
Patient First Name*
Patient Middle Name
Patient Last Name*
Patient Nickname
Patient DOB*
Patient SSN
Patient Preferred Language
Patient Gender*
- Male
- Female
Patient Race*
- Asian
- Black
- White
- Other
Patient Ethnicity*
- Hispanic
- Non-Hispanic
- Unknown
Patient Physical Address*
Patient Physical Address City*
Patient Physical Address State*
Patient Physical Address Zip*
Patient Mailing Address
Patient Mailing Address City
Patient Mailing Address State
Patient Mailing Address Zip
Patient Cell Phone
If age is > 12
Patient Email
If age is > 12
Patient Preferred Pharmacy
Patient Pharmacy City
Patient Pharmacy Phone
Primary Contact
C1 First Name*
C1 Middle Name
C1 Last Name*
C1 DOB*
C1 SSN
C1 Relationship*
C1 Marital Status
C1 Employer
C1 Occupation
C1 Email
C1 Primary Phone*
C1 Primary Phone Mobile
- This is a mobile phone
C1 Work Phone
C1 Work Phone Mobile
- This is a mobile phone
C1 Physical Address Same as Patient*
- Yes
- No
C1 Physical Address*
C1 Physical Address City*
C1 Physical Address State*
C1 Physical Address Zip*
C1 Mailing Address Same as Patient*
- Yes
- No
C1 Mailing Address
C1 Mailing Address City
C1 Mailing Address State
C1 Mailing Address Zip
C1 Appointments Contact Preferences
Select all that apply. All statements will be sent by US Mail.
- Primary Phone
- Work Phone
- Email
- Text Message
C1 Medical/Billing Contact Preferences
Select all that apply. All statements will be sent by US Mail.
- Primary Phone
- Work Phone
- Email
- Text Message
Secondary Contact
C2 First Name
C2 Middle Name
C2 Last Name
C2 DOB
C2 SSN
C2 Relationship
C2 Marital Status
C2 Employer
C2 Occupation
C2 Email
C2 Primary Phone
C2 Primary Phone Mobile
- This is a mobile phone
C2 Work Phone
C2 Work Phone Mobile
- This is a mobile phone
C2 Physical Address Same as Patient
- Yes
- No
C2 Physical Address
C2 Physical Address City
C2 Physical Address State
C2 Physical Address Zip
C2 Mailing Address Same as Patient
- Yes
- No
C2 Mailing Address
C2 Mailing Address City
C2 Mailing Address State
C2 Mailing Address Zip
C2 Appointments Contact Preferences
Select all that apply. All statements will be sent by US Mail.
- Primary Phone
- Work Phone
- Email
- Text Message
C2 Medical/Billing Contact Preferences
Select all that apply. All statements will be sent by US Mail.
- Primary Phone
- Work Phone
- Email
- Text Message
Billing
B_Responsible Party*
- Patient
- Primary Contact
- Secondary Contact
- Other
B_First Name*
B_Middle Name
B_Last Name*
B_Relationship*
B_Email
B_Primary Phone
B_Primary Phone Mobile
- This is a mobile phone
B_Work Phone
B_Work Phone Mobile
- This is a mobile phone
B_Mailing Address*
B_Mailing Address City*
B_Mailing Address State*
B_Mailing Address Zip*
Legal Information
L_Custodial Parent
If parents are divorced or separated, who has custody?
L_Legal Restrictions
Are there any legal restrictions that would restrict the noncustodial parent from consenting to medical treatment for the child or from obtaining information about the child’s medical treatment?
- No
- Yes
L_Other*
If yes, please explain and provide a copy of any legal paperwork that supports this restriction.
Emergency Contact (Not a Parent)
C3 Name*
C3 Relationship*
C3 Email
C3 Phone
C3 Phone Mobile
- This is a mobile phone
Insurance Primary Carrier
I1 Flag*
Do you have medical insurance?
- Yes
- No
I1 Carrier*
I1 Policy Holder Name*
I1 DOB*
I1 SSN*
I1 Gender*
- Male
- Female
I1 Employer*
I1 ID*
I1 Group*
Front of Insurance Card*
Please upload a copy of the front of your insurance card, or take a picture using your phone.
Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 5 MB.
Back of Insurance Card*
Please upload a copy of the back of your insurance card, or take a picture using your phone.
Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 5 MB.
Insurance Secondary Carrier
I2 Flag
Do you have a secondary insurance carrier?
- Yes
- No
I2 Carrier*
I2 Policy Holder Name*
I2 DOB*
I2 SSN*
I2 Gender*
- Male
- Female
I2 Employer*
I2 ID*
I2 Group*
Front of Insurance Card*
Please upload a copy of the front of your insurance card, or take a picture using your phone.
Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 5 MB.
Back of Insurance Card*
Please upload a copy of the back of your insurance card, or take a picture using your phone.
Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 5 MB.
Driver's License or State ID
Front of Driver's License*
Please upload a copy of the front of your driver's license or state ID, or take a picture using your phone.
Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 5 MB.
Signature
I request that payment of authorized Medicaid and/or commercial insurance bene! ts be made to Fairhope Pediatrics, Inc. for any service furnished to me or my dependent by Fairhope Pediatrics’ providers. I authorize Fairhope Pediatrics, Inc. to release medical information which may be required by my insurance carrier to determine payment for services rendered. I further understand that I am responsible to pay certain amounts due the physician. These amounts could include annual deductibles, copayments, charges denied as not covered by Medicaid or my commercial insurance carrier, and charges denied for services determined as not medically necessary. I further understand that if Fairhope Pediatrics, Inc. incurs any fees associated with collecting reimbursement on my account, I will be responsible for paying all of those fees.
S_Relationship*
Parent/Guardian Signature*
Hidden
Date
MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.

Connect With Us

Use the Patient Portal to message the clinic staff, schedule appointments, and request medication refills. You can also view your upcoming appointments, medications, lab results, health history, and more.

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Fairhope Pediatrics

19087-B Greeno Road
Fairhope, AL 36532

Phone
(251) 928-5568

Fax
(251) 928-2605

Email
info@fairhopepeds.com

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Office Hours

Call us to schedule an appointment.

Monday - Friday
8:00 am - 5:00 pm
Closed for lunch 12:00 pm - 1:30 pm

Saturday
8:00 am - 12:00 pm

We are required to report visits outside of normal business hours to your insurance provider. Appointments scheduled before 8am, after 5pm, and on Saturdays will incur an additional fee, which may be applied to your copay, coinsurance, or annual deductible.

By Appointment Only

To help us keep your children and other patients healthy, we are not accepting walk-ins at this time.

After-hours Care

If your child’s illness or injury is life-threatening, call 911.

Otherwise, call our office at any time to speak with a nurse.

After-Hours Nurse
(251) 928-5568

Poison Control Hotline
1 (800) 222-1222

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Email Address *

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Patient Demographics

Patient

Primary Contact

Secondary Contact

Billing

Legal Information

Emergency Contact (Not a Parent)

Insurance Primary Carrier

Insurance Secondary Carrier

Driver's License or State ID

Signature