Renaissance Pediatrics, P.C.
4012 Raintree Road, Suite 200A
Chesapeake, VA 23321
Office: (757) 488-2223
Fax: (757) 488-8398
Child’s Name: ____________________________________________
First
Middle
Last
Gender: □ Male □ Female
Ethnicity: □ Hispanic
Social Security #:_________________
Address: _________________________________________________
□ Non-Hispanic
Race: ___________________
Birth date: ____/____/____
City, State & Zip:__________________________________________
Preferred Language: _______________________________________
How did you hear about us? ______________________________
I am 18yrs or older and □give/□do not give access to my records to the
following people: ________________________________________
_____________________________________________________
Primary Telephone #:________________________________________
□ Home
□ Cell
□ Work
□ Other
Secondary Telephone #:_____________________________________
□ Home
□ Cell
□ Work
□ Other
Email Address: __________________________________________
I prefer to be reminded of appointments by phone: □ Yes □ No
If not, how? _________________________________________
□ Mother
□ Father
□ Stepmother
□ Guardian
□ Stepfather
□ Guardian
Name: ___________________________________________________
Name: ____________________________________________________
Address: _________________________________________________
Address: __________________________________________________
City, State & Zip: __________________________________________
City, State & Zip: ___________________________________________
Employer: ________________________________________________
Employer: _________________________________________________
SS# _______________DOB: ____________Work#:_______________
SS# _______________DOB: ______________Work#:______________
Home #: ______________________ Cell #: _____________________
Home #: ___________________ Cell#: _________________________
Preferred Primary Contact #:__________________________________
Preferred Primary Contact #:__________________________________
Primary Insurance
Additional Insurance
Policy Holder’s Name: __________________________________
Policy Holder’s Name: __________________________________
Relationship to patient: __________________________________
Relationship to patient: __________________________________
Birthdate: ____/____/____
S.S. #: _______________________
Birth date: ____/____/____ S.S. #: ________________________
Employer: _____________________________________________
Employer: ____________________________________________
Insurance Co.: __________________________________________
Insurance Co.: _________________________________________
Group #: ________________ Policy ID #: ____________________
Group #: _______________ Policy ID #: ____________________
Co-Pay: _____ Deductible: ________ Eff. Date: ______________
Co-Pay: _______ Deductible: __________ Eff. Date: _________
I authorize Renaissance Pediatrics, P.C. to release any information including the diagnosis and the records of any treatment or examination rendered to my
child during the period of care to third party payers and/or other health practitioners. I authorize and request my insurance company to pay directly to the
doctor or doctor’s group insurance benefits otherwise payable to me.
I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my
behalf or my dependents. If it becomes necessary to forward my account to a collection agency, I am aware that I will be responsible for all costs of
collections, which is currently $25.00 (subject to change).
_______________________________________________
Signature of Patient or Parent if Minor
(Responsible Party)
_____________________________
Social Security Number
___________________
Date
RENAISSANCE PEDIATRICS, P.C.
Phone: (757) 488-2223 Fax: (757) 488-8398
Pediatric Health History Form
Date: ______________
Patient’s Name: ___________________________________________________________________ Birth date: ____/____/____
Mother’s Name: ______________________________________________ Age: ________ Health Problems: ___________________________
Father’s Name: _______________________________________________ Age: ________ Health Problems: ___________________________
Sibling(s) Name & Age: ______________________________________________________________________________________________
Patient current medical problem(s): ______________________________________________Date Began: _____________________________
Current Medications: _________________________________________________________________________________________________
Serious Illness, Injury, Hospitalizations:
Year
Type of Illness, Injury, Surgery
_______
____________________________________________________________
_______
____________________________________________________________
List any know drug allergies/reaction: ___________________________________________________________________________________
Birth Weight: ____________ Length: _______________ Gestation Age of Delivery: Early <38 wks
Term 38-42 wks
Late > 42 wks
Home with mom/dad? Yes No Why not: ___________________________________________________________________________
Prenatal Complications: ______________________________________________________________________________________________
Was your baby: Jaundiced - Yes / No
Breast fed / Formula fed how long? ________________________________________
Delivery Hospital______________________________
Has your child ever had wheezing or bronchitis?
Has your child ever had chicken pox?
Do you have questions concerning the insertion of your car safety seat?
Do you have the phone number to poison control?
Do you wish to learn CPR?
Do you have any questions to discuss with the provider?
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Date/Age: ___________
Please identify health problems in the patient or blood relatives:
Condition
Alcohol/Drug Addiction
Allergies
Anemia/Blood Disorders
Asthma
Behavior Problems
Birth Defects
Bone/Joint Disease
Cancer
Chronic Diseases
Diabetes
Digestive Disorders
Eye/Ear Disorders
Patient/Relative
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
Condition
Genetic Disorders
Heart Disease
HIV/AIDS
Kidney Disease/Bed Wetting Issues
Lung Disease
Mental Illness/Retardation
Muscle Disorders
Rheumatic Fever
Rheumatoid Arthritis
Seizures/Epilepsy
Thyroid Disorders
Tuberculosis
Patient/Relative
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information
can be dangerous to my child’s health. It is my responsibility to inform the doctor’s office of any changes in my child’s medical status. I
authorize the healthcare staff to perform the necessary healthcare services my child may need.
Signature of Parent: _______________________________________________________________________ Date: ___________________
Reviewed by provider: ____________________________________________________________________ Date: ____________________
Provider Comments: _______________________________________________________________________________________________
i
RENAISSANCE PEDICATRICS, P.C.
4012 Raintree Road, Suite 200A
Chesapeake, VA 23321
Phone: (757)488-2223 Fax: (757)488-8398
I, ______________________________
the parent/legal guardian of _________________________________
(Please print)
(Please print)
Give the following person(s) permission to seek medical care for the above mentioned child in my absence. This
is to be effective on date signed and to remain in effect until further written notice is given.
The listed person(s) should be also considered as “emergency contacts” in the event that I am unable to be reached.
Name
Relationship to
patient
Phone Number(s)
(Please indicate
home, cell, work)
Access to
records
(check if yes)
Access to
financials
(check if yes)
*A photo ID will be required for all persons listed.*
_____________________________________________
(Signature)
_______________________
(Date)
I also give the person(s) listed above to sign for any vaccinations that are due to be given at the time of service.
______________________________________________
(Signature)
_______________________
(Date)
RENAISSANCE PEDIATRICS, P.C.
4012 Raintree Road, Suite 200A
Chesapeake, VA 23321
Office: (757) 488-2223
Fax: (757) 488-8398
Renaissance Pediatrics Financial Policy
Payment is required at the time services are rendered unless other arrangements have been made in advance. This includes
applicable coinsurance and co-payments for participating insurance companies. Renaissance Pediatrics accepts cash, personal
checks, Visa and MasterCard. There is a service charge for returned checks of $40.00.
Patients with an outstanding balance over 60 days must make payment arrangements prior to scheduling appointments.
Accounts with an outstanding balance over 60 days are subject to a one time late fee of $25.00. We realize that people have
financial difficulty. Therefore, we may advise that due to your financial situation you seek your child’s immunizations
through a clinic or health department.
Insurance
We bill participating insurance companies as a courtesy to you. It is your responsibility to provide all current and accurate
insurance information at the time of service. You are expected to pay your deductible and co-payments at the time of
service. If we have not received a payment from your insurance company within 45 days of the date of service, you will be
expected to pay the balance in full. You are responsible for all charges. We do bill secondary insurance companies as a
courtesy to you.
If you need assistance of have questions, please contact the Billing department between 8:00am to 4:30pm, Monday through
Friday.
Refunds
Overpayments will be refunded upon written request to the responsible party within 30 days.
Managed Care
If you are enrolled in a managed care insurance plan (i.e., HMO) you must receive a referral from our office before seeing a
specialist. NO retroactive referrals will be given.
MISSED APPOINTSMENTS/LATE CANCELLATIONS
Broken appointments represent a cost to us, to you and to the other patients who could have been seen in the time set aside for
you. Cancellations are requested 24 hours prior to the appointment. We request all appointments be confirmed; if we are
unable to confirm an appointment, we reserve the right to cancel the morning of the appointment. We reserve the right to
charge for any missed or late-cancelled appointments. Excessive abuse of scheduled appointments may result in discharge
from the practice.
I have read and understand Renaissance Pediatrics financial policy. I agree to assign insurance benefits to
Renaissance Pediatrics whenever necessary. I also agree that if it becomes necessary to forward my account to a
collection agency, in addition to the amount owed, I will be responsible for all costs of collections which is currently
$25.00 (subject to change).
Signature of Insured or Authorize representative: _________________________________________
Patient Name: ____________________________Patient D.O.B. ______________Date:___________
Renaissance Pediatrics, P. C.
4012 Raintree Road, Suite 200A Chesapeake, Virginia 23321. 757-488-2223 Fax: 757-488-8398
Sandra S. Baucom, M.D., F.A.A.P. – Partner
Dionne N. Harewood, M.D., F.A.A.P. – Partner
Michael P. Scaccia, M.D., F.A.A.P. - Partner
Jennifer L. McMurray, DNP, RN, CNNP, CPNP – Partner
David G. Dorbad, M.D.,F.A.A.P. - Partner
Spring Mangrum, M.D., F.A.A.P.
Anitha Malaisamy, M.D., F.A.A.P.
Cassie L. Roberts, D.N.P., R.N., C.P.N.P.,I.B.C.L.C.
Jennifer S. O’Connors, R.N., M.S.N., C.F.N.P.
Juli A. Granica, R.N., M.S.N., C.F.N.P.
This letter is to inform you that Renaissance Pediatrics has several policies in effect to ensure that all of our
patients well child exams are kept current and compliant with the American Academy of Pediatrics. We try to be
as accommodating as possible when scheduling as time is valuable. We also require appointments to be
confirmed 24 hours prior to enable all patients the same opportunity in preference of day and time.
If your child has missed the last three well child exams that have been scheduled in our office resulting in a “no
show” status of their account we will require all appointments be confirmed 24 hours prior to schedule day. Any
routine child care appointment that isn’t confirmed 24 hours prior will be canceled.
If the pattern of no show visits continue to occur, further action may be required. Thank you in advance for your
cooperation and understanding in this regard. If you have any further questions please to not hesitate to contact
our office.
Print Name: ___________________________________
Signature: ________________________________________
Date: ___________________________