healthy kids care

at sunrise

3196 S. MARYLAND PKWY STE 411 LAS VEGAS, NV 89109

P : (102) 444-1685

F : (102) 444-1916

Email : info@healthykidscarelv.org

Patient Demographics

Patient’s Name

First

Middle

Last

Date Of Birth

Sex

Male
Female

Age

Ethnicity

Parent / Guardian Information:

Name

First

Middle

Last

Insurance Date Name

Date Of Birth

Relationship To Patient

Name

First

Middle

Last

Date Of Birth

Relationship To Patient

Contact Information:

Address

Address Line 1

City

State

Zip Code

Primary Phone #

Secondry Phone #

Email

Emergency Contact

Phone #

Insurance:

(If The Patient Is Not Insured, Please Write “N/A”)

Primary Insurance

Member ID #

Group #

Subscriber’s Name

D.O.B

Secondary Insurance

Member ID #

Group #

Subscriber’s Name

D.O.B

Pharmacy:

Pharmacy Name

Phone #

Address

Address Line 1

Address Line 2

City

State

Zip Code