Patient Forms – Request to Schedule – Genetics Center

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Request To Schedule A Pediatric Appointment

Demographics Last Name * First Name * Middle Name Date of Birth (MM/DD/YYYY) *
Parent 1 Last Name Parent 1 First Name Parent 2 Last Name Parent 2 First Name
Home Address * City * State * Zip *
Phone Number (best contact number) * Phone Type:*    Cell     Home     Business Contact Person:*    Parent 1     Parent 2     Other
Phone Number (other) Phone Type:    Cell     Home     Business
Primary Language:    English        Spanish     Other:

Referral Source Information Referring provider * Referring provider office location * Primary Care Doctor

Medical Information Reason for being referred?
Do you have any family history of autism, down syndrome, or any other condition?:    Yes     No If yes, list condition(s)
Is the patient taking any medications?    Yes     No
List medications
Have you had any genetic testing?:    Yes     No
If yes, which tests?

Insurance Information Primary Insurance HMO or PPO?: HMO PPO Member ID #
If an HMO, medical group assigned to? Authorization Number
Secondary Insurance HMO or PPO?: HMO PPO Member ID #
If an HMO, medical group assigned to? Authorization Number

We will contact you at the best phone number listed above to assist you further.

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211 South Main Street, Orange, California 92868

1-888-4-GENETIC

contact@geneticscenter.com

Monday-Friday 8am-5pm

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