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Professional Pediatrics at The Jackson ClinicPatient Registration FormPLEASE PRINTName of Patient (First) (Middle) (Last) Preferred NameDate of Birth Sex Race Child’s Home PhoneChild’s Home Address City State ZipPerson Responsible for Paying & AddressFather’s Name SS# Date of BirthHome Phone Cell Phone EmailEmployer Work PhoneMother’s Name SS# Date of BirthHome Phone Cell Phone EmailEmployer Work PhoneParent’s Marital Status (Circle One) Single Married Divorced Separated Widow OtherDo we see any other siblings? Yes NoIf yes, give full nameIn case of emergency or unable to locate parents, please notify Relationship to ChildHome Phone Cell Phone Work PhoneWho referred you to our office?Does insurance apply to all siblings? Yes NoIf no, please explainPrimary Insuarance Company Primary Insurance HolderContract/Member ID # Group # Date of BirthSecondary Insuarance Company Primary Insurance HolderContract/Member ID # Group # Date of BirthIn signing below you are authorizing us to file claims and assign benefits to our physicians from Aetna, Allkids, BlueCross-PMD-PPO-Sefect, Bluecard PPO,CIGNA, Multiplan/PHCS (Private Healthcare Systems), Tricare-Standard, Tricare-Reserve Select, United Healthcare, Viva Health, and CHAMP/ VA. I understand I am responsible for all co-pays, deductibles and non-covered charges by my insurance carriers. If your child does not have this type coverage youare expected to pay for your child’s visit at the time of service in order to help keep the cost of health care down. Your insurance company will reimburseyou directly. You will receive two copies of our itemized statement: one for insurance purposes and the other for your tax records. In the event of hospitalization, if we have record of your insurance carrier, we will automatically file the hospital charges incurred for our doctor treating your child. In case ofdefault of payment and if this account is placed in the hands of a collector or any attorney for collection, all collection fees, attorney’s fees, costs and allother expenses will be paid by the undersigned.In signing below, you have read and understand our office policies and procedures and our NOTICE OF PRIVACY PRACTICES which tiave been provided foryou. You also declare that THIS CHILD AND ANY OF YOUR OTHER CHILDREN are not covered by Medicaid and that you do not plan to apply for Medicaid forthis child or any of your other children while patients of our practice.I understand that the physicians of Professional Pediatrics, P.C. use blood and/or blood products when, in their judgement, is a medical necessity. I dohereby consent to the administration of blood and/or blood products when my attending physician deems they are necessary for the proper treatment ofthe patient. I realize I am responsible for accompanying my child or children while on the premises.Patient/Guardian SignatureDate3/2021

CLEAR FORMInitial History QuestionnaireForm Completed By:Name:Initial Date Completed:ID Number:Date(s) Updated:Birth Date:Age:Sex:MFGENERALDo you consider your child to be in good health?Does your child have any special health care needs?Has your child ever been hospitalized?Is your child allergic to medicine or drugs? Yes Yes Yes Yes No No No No Don’t know Don’t know Don’t know Don’t knowSOCIAL HISTORYExplain:Explain:Explain:BIRTH HISTORYPlease list all those living in the child’s home.NameExplain:Relationship toChildBirth weight:Birth Date/Age Full-term Pretermweeks Post-termweeksDelivery: Vaginal Cesarean Reason:Any complications during birth or after birth? No YesExplain:Did the baby need to go to the NICU (neonatal intensive care unit)? No YesPlease list other siblings not living in the home.NameBirth Date/AgeWhere are they living?Explain:During pregnancy, did the mother:Take prenatal vitamins? YesSmoke or use e-cigarettes? YesDrink alcohol? YesUse marijuana? YesUse illicit drugs? YesTake other medications? Yes No No No No No No Unknown Unknown Unknown Unknown Unknown UnknownIf yes, please list:Blood type: Unknown UnknownMother:Does the child live with both biological parents? Yes NoIf no, what is the child’s current living situation? Single-parent custody Joint custody Adoptive family Other family members: Foster careBaby:Mother’s lab results:Hepatitis BHIVGroup B streptococcus (GBS) Pos Neg Unknown Pos Neg Unknown Pos Neg UnknownHow often does the child have visitation with parent(s) not living in the home?After birth, did the baby get:Vitamin K shot? Yes No Unknown Yes No Unknown Yes No Unknown Bottle formula Bottle breast milkErythromycin eye ointment?Hepatitis B shot?How was the baby fed? BreastfedHow long was baby breastfed?Did baby go home with biological mother from hospital after birth? No YesExplain:The recommendations in this questionnaire do not indicate an exclusive course of treatment or serve as a standardof medical care. Variations, taking into account individual circumstances, may be appropriate. Original questionnaireincluded as part of the Bright Futures Tool and Resource Kit, 2nd Edition. The American Academy of Pediatrics (AAP)does not review or endorse any modifications made to this questionnaire and in no event shall the AAP be liable forany such changes. 2019 American Academy of Pediatrics. All rights reserved.American Academy of Pediatrics Bright Futures https://brightfutures.aap.orgDownloaded From: http://toolkits.solutions.aap.org/ on 03/10/2021 Terms of Use: https://solutions.aap.org/ss/terms.aspxHE0564PAGE 1 of 4

Initial History QuestionnaireName:PAST MEDICAL HISTORYHas your child ever had any of the following problems? DK Don’t knowConditionDKNoYesDetailsEye problems, cataracts, or retinoblastomaVision impairment or concernsNasal allergies (dust, pets, orenvironmental)Frequent ear infectionsHearing loss or concernsMultiple cavities or problems with teethFrequent colds or sore throatsAsthma, wheezing, or breathing problemsBronchitis, bronchiolitis, or pneumoniaHeart murmur or other heart problemsHigh blood pressureFrequent stomach painConstipation needing medical treatmentFood allergies or intolerance(eg, milk, gluten)Feeding issues or underweightOverweight or obesityUrinary tract infectionsBed-wetting (after 5 years old)Kidney, ureter, or bladder problemsSerious injuries or fracturesBone, joint, or muscle problemsFrequent headaches or dizzinessConcussion or head injuryConvulsions, seizures, or neurologicalissuesSleep problems or snoringSkin rashes, eczema, or hivesAcneThyroid or other endocrine problemsDiabetesMetabolic/genetic disordersAnemia or bleeding problemsCancer or chemotherapyBone marrow or organ transplantPAGE 2 of 4American Academy of Pediatrics Bright Futures https://brightfutures.aap.orgDownloaded From: http://toolkits.solutions.aap.org/ on 03/10/2021 Terms of Use: https://solutions.aap.org/ss/terms.aspx

Initial History QuestionnaireName:PAST MEDICAL HISTORY (continued)Has your child ever had any of the following problems? DK Don’t knowConditionDKNoYesDetailsBlood transfusionHIV or AIDSChickenpox or zoster (shingles)Developmental delays (speech or motor)School problems or learning difficultiesADHD or behavioral concernsAnxiety, depression, or mood problemsTobacco, alcohol, or drug useExposure to family violencePregnancy or miscarriageSexually transmitted infectionsFemales: issues with periodsAge of first period:Other medical problems (Please list.)SURGICAL HISTORYHas your child ever had surgery?Surgery/Procedure No YesIf yes, please provide details below.Date of Surgery/Child’s AgeWhere CompletedDetailsOther surgical/procedural problems (Please list.)American Academy of Pediatrics Bright Futures https://brightfutures.aap.orgDownloaded From: http://toolkits.solutions.aap.org/ on 03/10/2021 Terms of Use: https://solutions.aap.org/ss/terms.aspxPAGE 3 of 4

Initial History QuestionnaireName:FAMILY HISTORYHave any of your child’s parents, grandparents, aunts, uncles, brothers, or sisters ever had any of the following conditions? DK Don’t knowConditionDKNoYesWho?DetailsAnemia or bleeding problemsAsthmaAllergiesAlcohol use problemsBed-wetting (after age 10 years)Cancer (before age 55 years)Childhood hearing lossDental decay or multiple cavitiesDepression or anxietyDevelopmental disabilityDiabetesHeart attack (myocardial infarction)Heart disease (before age 55 years)High blood pressureHigh cholesterolHIV or AIDSKidney diseaseLiver diseaseMental health conditionsObesitySeizures or epilepsyStrokeSubstance use problemsSudden death (before age 50 years)Thyroid or other endocrine diseaseTobacco use problemsTuberculosisVision or eye problemsOther medical problems (Please list.)PRINT NAME.Provider 1Provider 2PAGE 4 of 4SIGNATUREConsistent with Bright Futures:Guidelines for Health Supervision ofInfants, Children, and Adolescents,4th EditionAmerican Academy of Pediatrics Bright Futures https://brightfutures.aap.orgDownloaded From: http://toolkits.solutions.aap.org/ on 03/10/2021 Terms of Use: https://solutions.aap.org/ss/terms.aspx

RELEASE OF INFORMATION, BENEFIT ASSIGNMENT, PAYMENT AUTHORIZATION, FULL DISCLOSURE ANDAGREEMENT TO PAY FOR PROFESSIONAL SERVICES.I hereby authorize Jackson Clinic to release any information necessary to process any insurance claim acquired in the course of myexamination or treatment, to allow a photocopy of my signature to be used to process my insurance claim. I claim, direct, andauthorize my carrier to issue payment check(s) directly to Jackson Clinic for any insurance benefits to which I am entitled. Iunderstand that failure to disclose pre-certification/second opinion requirements for any and all plans to which I subscribe maycause me to incur full liability for professional charges as a result of non-payment by my carrier. I, the undersigned, accept the feecharged as a legal and lawful debt and agree to pay said fee, including any/all collection agency fees, (33.33%), attorney fees and/orcourt costs, if such be necessary. I waive, now and forever, my right of exemption under the laws of the constitution of the State ofAlabama and any other state. I understand that my insurance is filed as a courtesy, and I am responsible for the bill. I understandthat I am responsible for paying any deductible, co-insurance, co-payment, or service deemed non-covered/patient responsibility, bymy insurance carrier.Date:Signature of Patient or Guarantor:EXPRESS PRIOR CONSENT TO CONTACT CONSUMER BY CELL PHONEYou agree, in order for us to service your account or to collect monies you may owe, Jackson Clinic, and/or our agents maycontact you by telephone, at any telephone number associated with your account, including wireless telephone numbers, whichcould result in charges to you. We may also contact you by sending text messages or emails, using any email address you provideto us. Methods of contact may include using pre-recorded/artificial voice messages, and/or use of automatic dialing devices, asapplicable.I/we have read this disclosure and agree that Jackson Clinic, it’s employees and/or agents may contact me as described above.Responsible Party:Date:ACKNOWLEDGEMENT OF NOTICE OF HIPAAUnder the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use anddisclosure of your protected health information. These rights are described in the Notice of Privacy Practices. The Notice ofPrivacy Practices may be revised at any time. WE WILL PROVIDE YOU WITH A CURRENT COPY UPON YOUR REQUEST.By signing below, you are acknowledging that you have read or received a copy of the HIPAA policy. PatientName:Date:Signature:Date:If state authorized to act on behalf of patient please sign below:Name:Signature:Practice Use Only:I, attempted to obtain the acknowledgement of receipt of the HIPAA policy, but was unable to do so forthe following reason:Signature:Date:1-10748-1, 2/16