Inland Pediatrics

Patient Information

Name:

Sex:

Age:

Date of Birth:

Address: City State ZIP Code

If Patient is older than 12 yrs please provide his/her #:

Cell Phone number Guardian 1:

Cell Phone number Guardian 2:

Name of Father or Guardian:

Age:

Date of Birth:

Name of Mother or Guardian:

Age:

Date of Birth:

Insurance:

Policy Number:

Policyholders Full Name:

Drivers license/ID Number:

Emergency Contact:

Relationship:

Phone #:

Parent or Guardian’s Signature:

Date:

Consent Form

Patient Information

Last Name First Name

Date of Birth

Phone Number

Address

(Parent Name) am the legal guardian of the aforementioned child and understand that my son/daughter will be weighed, measured and sometimes have a hemoglobin for anemia, blood pressure, glucose or urine test. I also acknowledge that my child may require one of the following procedures.

Ear Lavage

Wound Care

Medicines IM /IV

Breathing tx

Penile Peel

Stitch Removal

Tongue Tie

Stool Removal

I understand that the services listed above are only performed when requested by me or if considered medically necessary. The risks and benefits, including organ damage, bleeding or continuation symptoms, are always a possible outcome. My signature here represents my consent for services and remains in place until I request a change prior to procedure(s).

(Your signature)

Consent for Child’s Vaccination:

I have read, or had explained to me, the vaccine information sheets and understand the risks and benefits. This authorization shall apply to any and all combinations of required and recommended California State Law and CDC childhood vaccines.

I consent to Inland Pediatrics, Inc. and its staff for my aforementioned child to be vaccinated with the full vaccine series for each childhood vaccine. I understand that I may withdraw consent at any time by informing the provider.

If this consent is not signed, your child will not be vaccinated.

Signature of parent/ legal guardian

Date

Inland Pediatrics, Inc

3838 Sherman Dr Ste 7
Riverside CA 92503
(951) 688-0361

Acknowledgment of Receipt of Notice of Privacy Practices

I acknowledge that I have received a copy of the Inland Pediatrics Notice Of Privacy Practices

Date:

(Fecha)

Patients Name:

(Nombre del Paciente)

Birth Date:

(Fecha de Nacimiento)

Parent/Guardian:

(Padre/Guardian)

Inland Pediatrics, Inc.

COMMUNICATION CONSENT AGREEMENT

I UNDERSTAND THAT UNDER FEDERAL LAW (HIPPA), THIS MEDICAL OFFICE MAY NOT RELEASE ANY MEDICAL INFORMATION TO ANY INDIVIDUAL WITHOUT MY EXPRESSED WRITTEN PERMISSION, LAW ENFORCEMENT AND COURT ORDERS ARE TWO EXCEPTIONS TO THIS REQUIREMENT. I, THEREFORE, GIVE MY PERMISSION TO INLAND PEDIATRICS, INC TO RELEASE MEDICAL INFORMATION TO THE FOLLOWING PERSON (S):

NAME:

RELATIONSHIP:

ADDRESS:

PHONE:

AGE:

DOB:

DRIVER’S LICENSE#:

OTHER FORMS OF IDENTIFICATION:

NAME:

RELATIONSHIP:

ADDRESS:

PHONE:

AGE:

DOB:

DRIVER’S LICENSE#:

OTHER FORMS OF IDENTIFICATION:

PATIENT NAME:

DOB:

PARENT SIGNATURE:

Date

CHILD HEALTH HISTORY

PATIENTS NAME:

PLACE OF BIRTH:

Did you (MOM) use any non-prescribed drugs? (tobacco, alcohol, “street drugs”, over the counter or home remedies)

YES

Did the baby go home with you from the hospital?

YES

Did the baby receive any shots for Hepatitis B?

YES

CHILD’S HISTORY:

MALE

FEMALE

Is this child adopted?

YES

Birth Weight:

Pounds Ounces

Length

Inches

Has your child ever had:

Measles, Chickenpox, Mumps,Rubella

YES

Skin problems

YES

Tuberculosis or Positive TB test

YES

Convulsions, seizures, epilepsy

YES

Problems with eyes or vision

YES

Diabetes

YES

Problems with ears or hearing

YES

Thyroid problems

YES

Heart problems

YES

Allergies

YES

Asthma, bronchitis, pneumonia

YES

Problems with developmental or school performance

YES

Anemia, bleeding problems, blood transfusions

YES

Serious illness or accident

YES

Diarrhea, solling self with stool

YES

Surgery or hospitalization

YES

Bladder or Kidney problems, wetting self or bed

YES

(Girls) has she started her periods? (Girls) Are there problems with her periods?

YES

FAMILY HISTORY: Does mother (M), father (F), brother (B), sister (S), aunt (A), uncle (U), or Grandparent (GP) have:

Diabetes

YES

Which Family Member ?

High blood pressure

YES

Which Family Member ?

Epilepsy or convulsions

YES

Which Family Member ?

Bleeding disorder

YES

Which Family Member ?

Mental retardation

YES

Which Family Member ?

Tuberculosis

YES

Which Family Member ?

Heart disease

YES

Which Family Member ?

Lung problems

YES

Which Family Member ?

Cancer

YES

Which Family Member ?

Breathing problems

YES

Which Family Member ?

Kidney or urinary disease

YES

Which Family Member ?

Bone or joint problems

YES

Which Family Member ?

PARENT INFORMATION:

Age

Mother Father

Height:

Mother Father

Occupation:

Mother Father

HOUSEHOLD INFORMATION:

Number of people in home:

Are both parents in the home?

YES

Does anyone in the home smoke, or use drugs or alcohol?

YES

Language spoken in the home:

Do you live in a:

Signature:

Date:

Relationship to Child:

Reviewer’s Signature:

Date:

INLAND PEDIATRICS

Statement of patient financial responsibility

Patients Name:

Signature

DOB:

Inland Pediatrics appreciates the confidence you have shown in choosing us to provide for your health care needs. The service you have elected to participate in implies a financial responsibility on your part. The responsibility obligates you to ensure payment in full for our fees. As a courtesy, we will verify your insurance coverage and bill your carrier on your behalf. However, YOU are ultimately responsible for payment of your bill in full.

YOU are responsible for payment of any deductible and or copays as determined by your contract with your insurance carrier. We expect these payments in a timely manner. Many insurance companies have additional stipulations that may affect your coverage. YOU are responsible for any amount not covered by your insurance. If your insurance carrier denies any part of your claim or if you elect to receive services past your approved period YOU will be held responsible for your balance in full.

I have read and agree with the above policy regarding my financial responsibility to Inland pediatrics, for providing services to me or the above named patient. I certify that the information is the best of my knowledge true and accurate. I authorize my insurer to pay any benefits directly to Inland Pediatrics for the entire amount of the bill incurred by me or the above named patient.

NEWBORNS

Baby is usually covered under moms insurance for the first 30 days of life. Private insurance (HMO’s and PPO’s) require that you add the baby to the policy being used at the time of visit and retroactive the start date to date of birth of the baby and assign the patient to Dr. Salazar as the provider. If the baby is not added or assigned to Dr. Salazar payment will be denied by the insurance provided and the payment will become the responsibility of the parent.

Signature

Parent or Guardian’s Name:

Parent's Guardian Signature

Date:

Social Determinants of Health

We believe everyone should have the opportunity for health. Some things like not having enough food or reliable transportation or a safe place to live can make it hard to be healthy. Please answer the following questions to help us better understand you and your current situation. We may not be able to find resources for all of your needs, but we will try and help as much as we can.

Food

Within the past 12 months, did you worry that your food would run out before you got money to buy more?

YES

Within the past 12 months, did the food you bought just not last and you didn’t have money to get more?

YES

Housing/ Utilities

Within the past 12 months, have you ever stayed: outside, in a car, in a tent, in an overnight shelter, or temporarily in someone else’s home (i.e. couch-surfing)?

YES

Are you worried about losing your housing?

YES

Within the past 12 months, have you been unable to get utilities (heat, electricity) when it was really needed?

YES

Transportation

Within the past 12 months, has a lack of transportation kept you from medical appointments or from doing things needed for daily living?

YES

Interpersonal Safety

Do you feel physically or emotionally unsafe where you currently live?

YES

Within the past 12 months, have you been hit, slapped, kicked or otherwise physically hurt by anyone?

YES

Within the past 12 months, have you been humiliated or emotionally abused by anyone?

YES

Optional: Immediate Need

Are any of your needs urgent? For example, you don’t have food for tonight, you don’t have a place to sleep tonight, you are afraid you will get hurt if you go home today.

YES

Would you like help with any of the needs that you have identified?

YES