Note: This is a reference translation to help you understand a typical form. It is not an official document. Your provider's actual form may differ — always sign the provider's own version.
When you receive this formYou receive this form before or at your child's first appointment at a new pediatric or family medicine practice — including before a scheduled well-child visit. Many practices send it home in advance or provide it online so you can complete it without rushing at the front desk.
What to bring or have readyBring your child's immunization records (the yellow card from WIC or a printed copy from a previous provider's patient portal), your insurance card, and any written diagnoses or specialist letters from prior providers. If you have a printed copy of the form completed in advance, bring it — most offices still ask you to confirm information on-site.
Child Information
English
What this field means
Child's Full Legal Name
Enter the name exactly as it appears on the birth certificate or legal ID. This must match your insurance records.
Date of Birth
Enter in month/day/year format (MM/DD/YYYY). The date of birth is used to verify insurance eligibility and to select age-appropriate screenings.
Sex Assigned at Birth
Used for clinical screening guidelines and insurance records. Options typically include Male, Female, and Other/Unknown. This field reflects biological sex for medical purposes.
Home Address
Include street address, city, state, and ZIP code. This is used for billing, appointment reminders, and determining in-network care options in your area.
Preferred Language
The language in which you and your child are most comfortable receiving care and information. Federal law requires providers to offer qualified medical interpreters at no cost when needed — see our guide on interpreter rights for details.
Parent / Guardian Information
English
What this field means
Primary Guardian Name, Relationship, Phone, and Email
The adult legally responsible for the child's healthcare decisions. Relationship options usually include Mother, Father, Stepparent, Grandparent, Foster Parent, Legal Guardian, or Other. Phone and email are used for appointment reminders, test results, and urgent clinical communications. Many practices offer a secure patient portal — ask about enrollment at your first visit.
Secondary Guardian (if applicable)
Name, relationship, and phone for a second parent or guardian who may accompany the child or be contacted in an emergency. Leave blank if there is only one guardian.
Custody or Legal Guardianship Notes
Use this field to note any custody arrangements, court orders, or restrictions that affect who may authorize treatment or pick up the child. The practice may request a copy of any court order on file.
Insurance Information
English
What this field means
Insurance Carrier Name
The name of the insurance company as printed on the front of your insurance card (for example: Aetna, BlueCross BlueShield, United Healthcare, Medicaid, CHIP). If your child has no insurance, ask the front desk about eligibility for Medicaid or CHIP, or about sliding-fee options at community health centers.
Member ID and Group Number
Both numbers appear on your insurance card. The Member ID identifies the insured person; the Group Number identifies the employer or plan sponsor. Enter both exactly as shown — a mismatch will delay claims.
Insurance Policyholder Name
The person in whose name the policy is held — often a parent or employer. If the child is the policyholder (for example, through CHIP or Medicaid), enter the child's name. Include their date of birth and relationship to the child.
Medical History
English
What this field means
Known Medical Conditions
List any diagnoses the child has received, such as asthma, diabetes, ADHD, or heart conditions. If none, write 'None known.' This information helps the provider coordinate care and avoid conflicting treatments.
Past Surgeries or Hospitalizations
List any operations or overnight hospital stays, including the approximate year and the reason. For example: 'Appendectomy, 2022' or 'Pneumonia hospitalization, 2021.' Leave blank if none.
Current Medications
List all prescription medicines, over-the-counter drugs, vitamins, and supplements the child takes regularly. Include the drug name and dose if known (for example: 'Fluticasone 44 mcg inhaler, twice daily'). Leave blank if none.
Allergies (medications, food, environmental)
List each allergen and the reaction the child had (for example: 'Penicillin — hives; Peanuts — anaphylaxis; Tree pollen — seasonal rhinitis'). Distinguishing a true allergy from a sensitivity or side effect helps the provider make safer prescribing decisions.
School or Daycare Name, Grade / Age Group
The school or daycare setting affects which vaccines or health screenings may be required for enrollment, and may also be relevant if the child has an individualized education plan (IEP) or needs accommodations.
Previous Primary Care Provider (if transferring)
If the child previously had a pediatrician or family doctor, the new practice may request records. Providing the prior provider's name and practice helps coordinate the transfer. HIPAA gives you the right to request and receive a copy of your child's records from any prior provider.
Permission to Share Health Information with School or Daycare
A yes/no consent field. When yes, the practice may share relevant health information (such as allergy action plans or medication instructions) directly with school nurses or daycare staff. You can revoke this consent at any time in writing.
Immunization History
English
What this field means
Immunization Records Provided
Check 'Records attached' if you are submitting a copy of the child's immunization records with this form. Records may include the yellow WIC immunization card, a printout from a previous provider's patient portal, or school immunization records. Your provider will review these against the current CDC-recommended immunization schedule. The CDC publishes the recommended immunization schedule at cdc.gov — your provider will compare your child's records against this schedule.
Up to Date per CDC Schedule (Yes / No / Unsure)
A simple checkbox or radio selection. If unsure, select 'Unsure' — your provider will review the attached records and advise on any gaps. Missing doses can often be caught up; your provider will discuss the right schedule for your child's age and health history.