Healthcare Infant Intake Form

HEALTHCARE INFANT INTAKE FORM

Infant Information

Infant Full Name:

Date of Birth:    Sex: Male Female Other

Birth Weight:    Gestational Age:

Delivery Type: Vaginal C-Section Assisted (forceps/vacuum)

Parent / Legal Guardian

Insurance Information

Medical History

Current Medications (include dose and frequency):

Allergies:

Prior Surgeries or Hospitalizations (describe with dates):

Chronic Conditions (check all that apply):

Developmental / Routine Care

Primary Care Provider Name:    Phone:

Immunizations up to date: Yes No

Feeding Method: Breastfeeding Formula Other

Household & Social History

Household Members (names, ages, relationship):

Tobacco use in home: No Yes    Drug use in home: No Yes

Authorizations and Acknowledgments

Consent for Treatment: I, as parent or legal guardian of the infant named above, authorize qualified medical practitioners, nurses and staff to provide routine and emergency medical treatment deemed necessary during evaluation and care. I understand that all medical treatment carries inherent risks. I acknowledge that the provider has explained the nature of routine evaluations, vaccinations, screenings and treatments applicable to infants and has offered the opportunity to ask questions prior to care.

Authorization to Administer Vaccines and Routine Medications: I authorize administration of routine immunizations and age-appropriate prophylactic medications (for example, vitamin K, erythromycin eye ointment) unless I have indicated otherwise in the immunization or allergy section above. I understand I may decline specific interventions and may withdraw consent at any time in writing.

Release of Records: I authorize the release of medical information necessary for treatment, payment and healthcare operations to my insurance carrier and other healthcare providers involved in the infant's care. This authorization does not limit protections afforded under applicable privacy laws. Authorization to release records expires on:

Acknowledgment of Privacy Practices: I acknowledge receipt of the provider's Notice of Privacy Practices and understand my rights with respect to the infant's protected health information, including the right to request restrictions and confidential communications. I understand that questions regarding privacy and health information can be directed to the provider's privacy official.

Accuracy Certification: I certify that the information provided on this intake form is complete and accurate to the best of my knowledge. I agree to notify the provider promptly of any changes to the infant's health status, medications, or insurance coverage.

Additional Instructions / Concerns

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