PEDIATRIC HEALTH, P.A. PLEASE PRINT AND COMPLETE ALL ENTRIES Patient Name (Last, First, MI) Date of Birth Sex Today's Date

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1 PEDIATRIC HEALTH, P.A. PLEASE PRINT AND COMPLETE ALL ENTRIES Patient Name (Last, First, MI) Date of Birth Sex Today's Date M F Address (Street, City, State, Zip) Home Phone Pt Social Security # () -_ Mother's Name (Last, First, MI) Date of Birth Social Security # Address/Phone if different from pt Employer Name & Address Work Phone Occupation Cell Phone () -_ Father's Name (Last, First, MI) Date of Birth Social Security # Address/Phone if different from pt ( ) - Employer Name & Address Work Phone Occupation Cell Phone () -_ ( ) - Sibling Name & DOB Sibling Name & DOB Sibling Name & DOB / / Sibling Name & DOB Sibling Name & DOB Sibling Name & DOB / / Emergency Contact Relationship Home Phone ( ) - Cell Phone ( ) - INSURANCE INFORMATION Primary Insurance Name Address (Street, City, State, Zip) Phone () -_ Name of Insured Effective Date ID Number Group # Secondary Insurance Name Address (Street, City, State, Zip) Phone () -_ Name of Insured Effective Date ID Number Group #

2 PEDIATRIC HEALTH, PA Please complete the following information as part of our compliance with The American Recovery and Reinvestment Act signed into law 2/17/2009. The State of New Jersey will begin their program in the fall of The purpose of the law is to preserve and improve affordable healthcare and outcomes. Thank you for your cooperation. Patient Name: Date of Birth: Language: English Spanish Other Race: Caucasian Black Hispanic Asian Native American Asian Pacific American Pacific Islander Subcontinent Asian American American Indian or Alaskan Native Native Hawaiian Black Non-Hispanic White Non-Hispanic Other Ethnicity: Latino/Hispanic Other Not Reported / Refused Assigned Provider: No preference Jose Lopez, MD Anthony Emanuel, MD Leo Lopez, DO Claudio Lopez, MD Diana Mayer, MD Marta Zeb, MD Melissa Bonilla, MD Michelle Teresh, MD Kathleen Swayne, MD Allergies No Known Allergies Yes, Please list Current Medications: No Medications Yes, Please list Major Health Problems: No Health Problems Active problems, Please list

3 Patient Medical History Patient Name (Nombre) DOB (Fecha de Nacimiento) / / Parent(s)/Legal Guardian Name(s) (Críe (s) /Nombre legal de Guardián (s)) _ If not birth parent(s), please provide legal documents (Si no padres de nacimiento, proporcionan por favor documentos legales) Pregnancy & Birth (Embrarazo y Nacimiento) Mother s age at pregnancy (La edad de la madre en embarazo) Any medical problems during pregnancy (Algún problema médico durante embarazo) Medications during pregnancy (exclude vitamins and iron), Las medicinas durante embarazo (excluya vitaminas e hierro) Explain (Exlica) Smoking, Alcohol, Non-Prescription drugs during pregnancy (El fumar, el Alcohol, las drogas sin receta durante embarazo) Explain (Exlica) Birth Hospital (Dé a luz al Hospital) _ Obstetrician (Obstetra) Was baby full term (Fue bebé término lleno)? Y N Premature (Prematuro)? Y N Delivery by (La entrega por): vaginal birth caesarian Apgar Score (La Cuenta de Apgar): Birth Weight (Dé a luz a Peso) _ Discharge weight (Descargue peso) Length(Longitud) _ Delivery Complications (Las Complicaciones de la entrega)? Problems with baby at birth (Los problemas con bebé al nacer?) Patient Past Medical History Medications/Vitamins on a regular basis (Las medicinas con regularidad) Hosptializations/Operations (with dates) (Las Hosptializations/operaciones (con fechas)) Serious Injuries/Fractures (include dates) (Heridas/Fractura graves (incluya las fechas)) Allergies (Alergias) Please list all allergies (Por favor enumere todas las alergias) Seasonal/Environmental (de estaciones/de ambriente) Medication (Medicamento) Food (Comida) Other (Otro) Development & Behavior (Desarrollo & Behavior) Age at which the child (Edad a la que el niño): Used Sentences (Frases usadas) Sat Alone (Se sentó Alone) Walked Alone (Caminó Alone) Toilet Trained (Inodoro formado) Attending School? ( Asistía a la escuela?) Y N Problems in school (Problema en la escuela) Y N Grade (Grado) Learning problems (Problemas de aprendizaje) Y N Behavior problems (Problemas de comportamiento) Y N Bedwetting (Enuresis) Y N Sleep problems (Problemas del sueño) Y N Feeding & Nutrition (Alimentación & nutrición) Appetite usually good (Apetito suele ser bueno) Y N Colic or feeding problems in 1st 3 months? ( Cólico o problemas de alimentación en 1ª 3 meses?) Y N Breast Feeding? ( Lactancia materna?) Y N Until what age (Hasta qué edad) Formula Feeding? (Fórmula de alimentación) Y N Current Brand (Marca actual) Vitamins (Vitaminas) Y N Brand (Marca) Special Diet (Dieta especial)

4 Patient Medical History Had child had any of the following diseases (Tiene a su niño tuvo cualquiera de las enfermedades siguientes): Rubella (German measles) (La rubéola) Mumps Chickenpox Anemia TB Tuberculosis Urinary infections (Infecciones urinarias) Lymes Meningitis Strep Throat (Inflamación de la garganta) Ear Infections (Infecciones de oreja) Eczema/Hives Developmental Disorders (Trastornos del Desarrollo) Heart Murmur (Soplo en el corazón) Hepatitis Seizures (Tomas) Pneumonia (Pulmonía) Scarlet Fever (Escarlatina) Allergies (Alergias) Bedwetting Problems (Mojar la cama Problemas) Family History List blood relatives of child who ve had the following problems use abbrev. (Lista de parientes de sangre del niño que han tenido los siguientes problemas utilizar abbrev) M :Mother (Madre) F: Father (Padre) B : Brother (Hermano) S : Sister (Hermana) MM : Mother s Mother (Madre de la madre) MF : Mother s Father (Padre de la madre) FM : Father s Mother (Madre del padre) FF : Father s Father (Padre del padre) A : Aunt (Tia) U : Uncle (Tio) C : Cousin (Primo) Cancer - Diabetes HIV/Aids Asthma Artritis Tuberculosis Developmental Disorders (Trastornos del Desarrollo) Heart Disease (Enfermedad del corazón) Anemia/Blood Disorder (Irregularidades en la sangre) Colesterol Problem (Problema de colesterol) Cystic Fibrosis (Enfermada de los pulmones fibrocisticas) Early Deafness (Sordo a temprana edad) Family Profile (Perfil de la familia) Alcoholism (Alcoholismo) _ Birth Defects (Defectos de nacer) _ Epilepsy/Seizures (Epillepsia/Ataques) Drug Problems (Problema de droga) _ High Blood Pressure (Alta presion) _ Migraine (Migrana) _ Parents (Padres): Married (Se casó con): Divorced (Se divorció de) Seperated (Separados) Other (Otro) # in Household (# en casa) # Smokers in household (# Los fumadores en hogar) # Use Street Drugs (# El uso de drogas de la calle) # Abuse Alcohol (Alcohol # Abuse) Pets (Mascotas) With whom does the child reside with (Con quien does el niño residen con) I acknowledge receipt of Pediatric Health, PA s Notice of Privacy Practices: Child Name Child DOB: Name of person completing Signature Relationship Date PEDIATRIC HEALTH, PA ACKNOWLEDGEMENT AND RECEIPT OF VACCINE POLICY I have received and read a copy of the Pediatric Health, P.A. Vaccine Policy Statement. I understand the terms and conditions contained herein. Parent/ Guardian Signature Date:

5 PEDIATRIC HEALTH, P.A. PRACTICE POLICY Thank you for choosing PEDIATRIC HEALTH, P.A. as your health care provider. We are committed to your child s good health. Please understand that payment of your child s bill is considered part of your child s medical care. In accordance with current HIPAA requirements, we may disclose you or your child (ren) s patient health information with your consent for the purposes of: 1. Treatment, 2. Payment, or 3. Health care operations relating to PEDIATRIC HEALTH, P.A. The following is a statement of our Practice Policy, which we require you to read and sign prior to any treatment. All information must be completed before seeing the doctor. FULL PAYMENT IS DUE AT TIME OF SERVICE. WE ACCEPT cash, check, money order and credit cards including Visa, MasterCard, Discover, and American Express. Regarding Insurance Your insurance policy is a contract between your and your insurance company. Please be aware that some, and perhaps all, of the service provided may be non-covered services and not considered reasonable and necessary under the Medicaid Program and/or other medical insurance. Therefore, the guarantor will be responsible for the full payment of the bill. Co-pay Policy All co-pays and deductibles are due prior to treatment. If the child needs to be seen for multiple visits a co-pay is due for each visit. It is against the law to waive co-pays. We will not waive the co-pay fee for multiple visits. No Show Policy Pediatric Health requires 24 hour notice of cancellation of all physical/well appointments. A fee of $20.00 per child will be charged if such notice is not given. Pediatric Health reserves the right to dismiss any patient from the practice who does not comply with this policy. Minor Patients The adult accompanying a minor and the parents (or guardians of the minor) are responsible for full payment. Interest We reserve the right to charge interest in the amount of 1.5% as provided by state law for unpaid balances. Balances over 90 days old will be referred to collection accounts and our service will be withdrawn. Insurance Authorizations I hereby authorize PEDIATRIC HEALTH, P.A. to furnish information to my insurance carriers, and I hereby assign to PEDIATRIC HEALTH, P.A. all payments for medical services rendered to me/dependents. Thank you for understanding our Practice Policy. Please let us know if you have questions or concerns. I have read the Practice Policy. I understand and agree to this Practice Policy: X Date_ Signature of Patient or Responsible Party X Date_ Signature of Co-Responsible Party

6 PEDIATRIC HEALTH, P.A. Infants, Children, Young Adults Jose R. Lopez, M.D., F.A.A.P Anthony Emanuel, M.D., F.A.A.P. Claudio Lopez, M.D., F.A.A.P. Diana Mayer, M.D., F.A.A.P. Leonardo N. Lopez, D.O., F.A.A.P. Marta Zeb, M.D., F.A.A.P Melissa Bonilla, M.D., F.A.A.P. Michelle Teresh, M.D. Kathleen Swayne, M.D., F.A.A.P. 470 Stillwells Corner Rd Rd Freehold, NJ (732) Rt. 9 North Howell, NJ (732) Kilmer Drive, Suite B Morganville, NJ (732) Patient Name: DOB: DOB: DOB: 69 West Main Street Freehold, NJ (732) Rt. 9 South Howell, NJ (732) Parent(s)/Guardian(s): I,, the parent/guardian of the name(s) listed above, authorize the following list of people to bring my child(ren) to Pediatric Health in the absence of my presence for medical treatment and vaccinations. Parent/Guardian Signature: Date: Name Address Relation

7 New Jersey Department of Health Vaccine Preventable Disease Program P.O. Box 369, Trenton, NJ (Fax ) NEW JERSEY IMMUNIZATION INFORMATION SYSTEM (NJIIS) CONSENT TO PARTICIPATE - RETAIN A COPY OF THIS FORM IN THE MEDICAL RECORD Registrant Name (Print) REGISTRANT INFORMATION PARENT/GUARDIAN INFORMATION (if NJIIS Registrant is a minor) Name (Print) Date of Birth Address Country of Birth City, State, Zip Code Name of Primary Health Care Provider Pediatric Health, PA Relationship to Registrant I have received information about the New Jersey Immunization Information System (NJIIS) and understand that the purpose of this program is to help remind me when my/my child's immunizations are due and to keep a central record of my/my child's immunization history. I understand that the medical information in the NJIIS may be shared with authorized health care providers, schools, licensed child care centers, colleges, public health agencies, health insurance companies, and others as permitted by New Jersey Law at N.J.S.A. 26:4-131 et seq. and rules at N.J.A.C. 8:57-3. I understand that I can get a copy of my/my child's record from my primary health care provider, my local health department, or the New Jersey Department of Health (NJDOH). The NJDOH may be contacted at the website or telephone number listed above. There is no cost to participate in this program. Yes, I would like to participate in this program. No, I do not want to participate in this program. Signature of Registrant (or Parent/Guardian, IF Registrant under 18 Years of Age) Date Name of NJIIS Enrollment Site Registry ID Number Medical Record Number - RETAIN A COPY OF THIS FORM IN THE MEDICAL RECORD - IMM-32 JUL 12

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