Child Patient Registration

Patient Registration Form for Child, MANA Family Medicine Prairie Grove

  • Please enter number without hyphens.
  • Please include street and city so we know which branch you prefer.
  • Person Responsible for Payment

    Guardians and foster parents, please complete the parent information and indicate that the child is in your custody.
  • Please enter numbers without hyphens.
  • Please enter number without hyphens.
  • Emergency Contact Information

  • Patient Notice of Privacy Practices Acknowlegement

    If you would like to authorize MANA clinic to release information to a family member, spouse, or personal representative, please complete the Individual Authorization Form at the bottom of this document.
  • I have received a copy of the Patient Notice of Privacy Practices from Medical Associates of Northwest Arkansas.
  • Choosing "Yes" below is my electronic signature.
  • In the event this Acknowledgement form is being executed by a personal representative, guardian or parent, please give your name, date of birth, social security number and relationship to the patient here:
  • How did you hear about us?

    Thank you for choosing a MANA clinic. How did you hear about us? Check all that apply.
  • Use the shift key to choose more than one option.
  • Health Insurance Information

    Please provide a copy of your insurance card to the receptionist. Fill out Medicare information if you use Medicare.
  • Company Name
  • Company Name
  • PATIENT AUTHORIZATION I hereby authorize Medical Associates of Northwest Arkansas {MANA), in its sole discretion, to seek payment of charges for all services rendered during or in connection with my medical treatment from my insurer and/or from third parties {or their insurers} who may have caused, or otherwise be liable for, the incident, injury or condition giving rise to my need for medical treatment. I understand that in the event MANA attempts to collect from those third parties, such attempts are in lieu of, or in addition to, MANA seeking payment from my current medical insurance provider. I understand and agree that any discounts which MANA has agreed to accept from my medical insurance provider will not be applied to reduce amounts payable by, or recoverable from, third parties or their insurers. I hereby assign and authorize payment directly to MANA of all insurance benefits, sick benefits and injury benefits due because of liability of a third party and proceeds of all claims resulting from the liability of a third party to me or for my benefit unless all charges are paid in full immediately upon completion of my medical treatment. I further agree that this assignment will not be withdrawn at any time until the account is paid in full and consent to MANA's assertion of subrogation or lien rights, if necessary, to protect MANA's interest in recovering from third parties the full amount of charges for services rendered during or in connection with my medical treatment. I agree to pay at the time of service any co-pay or amount otherwise required by my current medical insurance provider and understand that I am responsible for any amount not covered by Insurance or collected by MANA from a third party. MANA Is authorized to give information regarding me, my case and my medical treatment to my current medical Insurance provider and/or to potentially financially responsible third parties and their insurers. By choosing YES below I sign this statement.
  • Child Health History

    Your child's overall health as well as any medications your child takes could have an important interrelationship with the care your child receives. Please answer each of the following questions completely.
  • Please check any problems your child currently has or has ever had. Use the shift key to choose more than one option.
    If child is of school age
  • Pregnancy/Birth History

  • Past Medical/Surgical History

  • Use the shift key to choose more than one option.
  • DateHospitalization or illnessHospital/PhysicianCity/State 
    Add a new row
    Use the + button to make more rows if needed.
  • DateMedications/StrengthFrequencyCondition 
    Add a new row
    Use the + button to make more rows if needed.
  • Please list all allergies, sensitivities, and/or reactions to any drugs.
  • Child's Father

  • Child's Mother

  • Other Family Members

  • Please list age, state of health, age at death, and health conditions for any siblings. Use the + button to add more rows.
    Sibling 1Sibling 2Sibling 3 
    Add a new row
  • Mark any diseases known to have occurred in the family with the appropriate initial: M(Mother), F(Father), GM (Grandmother), GF(Grandfather), A(Aunt), U(Uncle), C(Cousin), B(Brother), S(Sister). Use the + button to add more rows if needed.
    AlzheimerAsthmaAlcoholismBlood DiseaseCoronary Artery DiseaseCancerStrokeDepressionDevelopment ProblemsDiabetes 
    Add a new row
  • Hearing ProblemsCholesterolHigh Blood PressureMental DiseaseMigrainesObesityBlood ClotsKidney ProblemsSeizuresSickle Cell 
    Add a new row
  • Please list your preferred pharmacy, with street and city.
  • To the best of my knowledge, the questions on this form have been accurately answered.I understand the providing incorrect information can be dangerous to my child's health. It is my responsibility to inform the doctor's office of any changes in my child's medical status. I also authorize the healthcare staff to perform the necessary services my child needs.
  • Authorization to Individuals

    I give all physicians and professional staff employed by Medical Associates of NWA, PA, permission to disclose the protected health information set forth below to the following people at the request of one or more of these individuals.
  • Use + button to add more rows
    NameRelationship to patientPhone 
    Add a new row
  • In addition, I understand or acknowledge the following: 1. I understand that Medical Associates of Northwest Arkansas, P.A ., will not release any information to any person(s) not listed above. 2. I have the right to revoke this Authorization at any time by giving Medical Associates of Northwest Arkansas, P.A., a written notice. I understand this does not apply to the release of PHI pursuant to my prior authorization. 3. I have received Medical Associates of Northwest Arkansas’s Notice of Privacy Practices 4. My protected health information may be subject to re-disclosure by one or more of the persons named above and as such may no longer be protected by federal or state law. 5. My treatment is not conditional on signing this statement, except as allowed by Privacy Rule.
  • In the event the Authorization is being executed by a personal representative, guardian, or parent, please print your name, relationship to the patient, and basis of authorization to act on the patient’s behalf.