CONTACT APPOINTMENTS DIRECTIONS
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Julia Barriga M.D. P.A.

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Julia Barriga M.D. P.A.

Patient/ Family Registration Form

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Patient/ Family Registration Form

PRIMARY CONTACT PERSON FOR FAMILY

(This will be the person to receive appointment reminders)

Preferred method of contact and Appointment Reminders

Recalls: past due shots, physicals exam 

Patient/ Family Registration Form

SECONDARY CONTACT PERSON FOR FAMILY

Preferred method of contact



Appointment Reminders

Recalls: past due shots , physicals exam

In order to obtain more accurate Family Medical History requirements, if contacts listed above are NOT the BIOLOGICAL PARENTS, we now necessitate BOTH BIOLOGICAL PARENTS (if known) to be listed (fill in any and all information if known):

If either biological parent listed above has NO parental rights per a SIGNED COURT ORDER, a copy of that COURT ORDER is required to be on file.

Patient/ Family Registration Form

EMERGENCY CONTACT PERSON

(Other than either the parent(s) or contact(s) listed above)

LIST ONLY CHILDREN IN FAMILY THAT THE ABOVE PARENTAL INFORMATION APPLIES TO
(If children have a different family dynamic then above - they must be on a different sheet)


First Child:

Second Child:

Third Child:

Fourth Child:

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