Hartford Area Pediatrics: Registration Form

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HARTFORD AREA PEDIATRICS, P.C.
THOMAS B. BINDER, M.D.
43 West Main Street – Avon, CT 06001
Phone 860-678-9400 – Fax 860-678-9480

Registration Information
(records must be updated annually)

Date ________________________

Patient Name _______________________________________________________________________ SSN# _____-___-_____

Gender ______________ DOB ____/____/____ Allergies ________________________________________________________

Street Address __________________________________________________________________________________________

City ______________________________________ State _____ Zip _____________ Home Ph. _________________________

Previous Doctor _________________________________________City ______________________ Ph.____________________

Sibling Information

Name __________________________________________________ Gender ____________________ DOB ____/____/_______

Guardian Information

PLEASE SHOW PATIENT’S INSURANCE CARD UPON COMPLETION OF THIS FORM