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"*" indicates required fields

Parent/Guardian 1

Role*

Father

Mother

Guardian

Name*

First Middle Last

Date of Birth*

MM slash DD slash YYYY

Cell Phone*

Ethnicity/Race*

Employer Name*

Employer Phone*

Employer Address*

Street Address Address Line 2 City State ZIP Code

Parent/Guardian 2

Role

Father

Mother

Guardian

Name

Prefix First Last Suffix

Cell Phone

Date of Birth

MM slash DD slash YYYY

Ethnicity/Race

Employer Name

Employer Phone

Employer Address

Street Address Address Line 2 City State ZIP Code

Home

Marital Status

Married

Single

Divorced

What language do you speak at home?*

Home Phone*

Email Address*

Billing Address*

Street Address Address Line 2 City State ZIP Code

Physical Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contact

Emergency Contact Name*

Emergency Contact Phone*

Patient Information

Name*

First Middle Last

Date of Birth*

MM slash DD slash YYYY

Ethnicity/Race*

Gender*

Male

Female

Insurance Information

Insurance Status*

I do not have insurance

Primary Insurance

Primary Insurance Options

Copay Not Required

Insurance Company Name*

Insurance Address*

Street Address Address Line 2 City State ZIP Code

Subscriber Name*

Subscriber Group Number*

Subscriber Date of Birth*

MM slash DD slash YYYY

Insurance Effective Date*

MM slash DD slash YYYY

Subscriber Insurance ID*

Secondary Insurance

Primary Insurance Options

Copay Not Required

Insurance Company Name

Insurance Address

Street Address Address Line 2 City State ZIP Code

Subscriber Name

Subscriber Group Number

Subscriber Date of Birth

MM slash DD slash YYYY

Subscriber SSN

Insurance Effective Date

MM slash DD slash YYYY

Subscriber Insurance ID

Third Insurance

Primary Insurance Options

Copay Not Required

Insurance Company Name

Insurance Address

Street Address Address Line 2 City State ZIP Code

Subscriber Name

Subscriber Group Number

Subscriber Date of Birth

MM slash DD slash YYYY

Insurance Effective Date

MM slash DD slash YYYY

Subscriber Insurance ID

Consent

I authorize assignment of benefits to Just 4 Kids Pediatrics and Mountain Peak Pediatrics and authorize previously named clinic to release any information requested to receive payment.

Authorized Individuals for Pickup/Treatment

Authorized Individuals

Authorized Name

Relationship to Child

Signature

Date

MM slash DD slash YYYY

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Pediatric urgent care, virtual visits, and mental health support under one trusted team – serving families across Eastern Idaho.

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