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Early Learning Center
Pediatrics
Updates and Closures
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Home
Early Learning Center
Pediatrics
Updates and Closures
Contact Us

Home
Early Learning Center
Pediatrics
Updates and Closures
Contact Us

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New Patient Registration

Home > New Patient Registration

1Patient Information

2Responsible Party Information

3Primary Insurance Information

4Secondary Insurance Information

PATIENT INFORMATION
Patient's Name
First Last
Physical Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Work Phone
Cell Phone
Gender
- Male
- Female
Social Security Number

Note: You may alternatively provide this information on your first visit.
Date of Birth
MM slash DD slash YYYY

Responsible Party Information
Father's Name
First Last
Social Security Number

Note: You may alternatively provide this information on your first visit.
Date of Birth
MM slash DD slash YYYY
Father's Email
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Work Phone
Cell Phone
Marital Status
- Married
- Single
- Divorced
- WIdowed
- Legally Separated
- Other
Employment Status
- Full TIme
- Part Time
- Self Employed
- Unemployed
- Student
- Retired
Employer
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mother's Name
First Last
Social Security Number

Note: You may alternatively provide this information on your first visit.
Date of Birth
MM slash DD slash YYYY
Mother's Email
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Work Phone
Cell Phone
Marital Status
- Married
- Single
- Divorced
- Widowed
- Legally Separated
- Other
Employment Status
- Full Time
- Part Time
- Self Employed
- Unemployed
- Student
- Retired
Employer
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Insurance Information
(Provide your insurance card to the front desk at check in)
Name of Insured
First Last
Patient Relationship to Insured
Insurance Company
Insurance Company Phone Number
Subscriber ID (Policy Number)
Group ID
Effective Date
MM slash DD slash YYYY
Termination Date
MM slash DD slash YYYY
Insured Date of Birth
MM slash DD slash YYYY
Insured Social Security Number

Note: You may alternatively provide this information on your first visit.
Insured Employer
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Secondary Insurance Information
Name of Insured
First Last
Patient Relationship to Insured
Insurance Company
Insurance Company Phone Number
Subscriber ID (Policy Number)
Group ID
Effective Date
MM slash DD slash YYYY
Termination Date
MM slash DD slash YYYY
Insured Date of Birth
MM slash DD slash YYYY
Insured Social Security Number

Note: You may alternatively provide this information on your first visit.
Insured Employer
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Company Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
I agree that the information supplied on this form is accurate and up-to-date to the best of my knowledge. I authorize the release of any information requested by my insurance carrier(s) that is necessary to process unpaid claims and also authorize payment "assigned" insurance benefits to The Doctors Luce Pediatrics, LLC
Patient (or Responsive Party) Signature
Date
MM slash DD slash YYYY
Electronic Approval
- Use my name here as a digital signature

Quick Links

New Patient Registration
Request an Appointment
M-CHAT
TB/LEAD Assessment
Immunization Schedule

Resoruces

New Patient Registration Form

Notice of Privacy Practices

Consent Form

Release Form

16280 N.W. Bethany Court Beaverton, OR 97006

Phone: (503) 713-5330

Fax: (503) 334-1256

Active Kids

Our kids learn how to seek out exercise, fresh air, and activity!

Pediatric Hours

Mon-Fri: 8:00am to 4:00pm
Sat & Sun: Closed

Daycare Hours

Mon-Fri: 6:00am to 6:00pm
Sat & Sun: Closed

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