Patient Data Collection Form - Pediatrics

Pediatric Patient Registration

Patient Data – Pediatrics

TAJ Card Information. Hungarian National Health Insurance will NOT be accepted for payment.

My Child has TAJ Card Number and I can upload a Copy of the TAJ Card

My Child does not have a TAJ card number

I do not know my Child’s TAJ card number or I cannot upload a Copy of the TAJ Card now

Child’s TAJ Card Number – 9 digits.

Upload a Copy of the Child’s TAJ Card!

Choose File (pdf, jpeg, jpg, png, bmp, gif)

The Child’s Photo Identification Document, preferably Passport, alternatively Local Residence Permit or Country’s National Identification Card Serial Number.

Upload a Copy of the Data Page of the Child’s Passport or both sides of any other types Photo Identification Cards! The Document must contain the Photo of the Person’s face.

Choose File (pdf, jpeg, jpg, png, bmp, gif)

Family (Last) Name of Child

Given (First) Name of Child

Birth Name. Is the Child’s Name now the same that he/she had on his/her Birth Certificate?

Yes, the name is the same that he/she had at Birth.

No, He/she had a name change since Birth for certain reasons.

Birth Name (Family) of Child

Birth Name (Given) of Child

Mother’s Maiden Family (Last) Name

Mother’s Maiden Given (First) Name

Gender of Child – in Hungary only Male or Female Genders are officially recognized.

Male

Female

Place of Birth – Country

Place of Birth – Town, City

Date of Birth, Year-Month-Day

Permanent (Home) Address of Child

Street Name and Number

Additional Information about Address (e.g. c/o)

City, Town

State, County, Region

Zip (Postal) Code

Country of Permanent (Home) Address

Primary Responsible Adult

Parent Number 1 – Mother

Parent Number 2 – Father

Significant Other – such as Relatives or Legal Guardian

Second Responsible Adult

Parent Number 1 – Mother

Parent Number 2 – Father

Significant Other – such as Relatives or Legal Guardian

There is no Second Responsible Adult

Third Responsible Adult

Parent Number 1 – Mother

Parent Number 2 – Father

Significant Other – such as Relatives or Legal Guardian

There is no Third Responsible Adult

Last (Family) Name of Parent 1 – Mother

Given (First) Name of Parent 1 – Mother

Parent 1 – Mother’s Photo Identification Document, preferably Passport, alternatively Local Residence Permit or Country’s National Identification Card Number.

Upload a Copy of the Data Page of Parent 1 – Mother’s Passport or both sides of any other types Photo Identification Cards! The Document must contain the Photo of the Person’s face.

Choose File (pdf, jpeg, jpg, png, bmp, gif)

Last (Family) Name of Parent 2 – Father

Given (First) Name of Parent 2 – Father

Parent 2 – Father’s Photo Identification Document, preferably Passport, alternatively Local Residence Permit or Country’s National Identification Card Number.

Upload a Copy of the Data Page of Parent 2 – Father’s Passport or both sides of any other types Photo Identification Cards! The Document must contain the Photo of the Person’s face.

Choose File (pdf, jpeg, jpg, png, bmp, gif)

Relationship of Significant Other Responsible Adult’s Relationship to the Child

Family (Last) Name of Significant Other

Given (First) Name of Significant Other

Significant Other’s Photo Identification Document, preferably Passport, alternatively Local Residence Permit or Country’s National Identification Card Number.

Upload a Copy of the Data Page of Significant Other’s Passport or both sides of any other types Photo Identification Cards! The Document must contain the Photo of the Person’s face.

Choose File (pdf, jpeg, jpg, png, bmp, gif)

Address of Parent(s) – Responsible Adult(s) is the same as for the Child

Yes

Different Address of Responsible Adults

Parent 1 – Mother

Parent 2 – Father

Significant Other, Legal Guardian

Permanent (Home) Address of Parent 1 – Mother

Street Name and Number

Additional Information about Address (e.g. c/o)

City, Town

State, County, Region

Zip (Postal) Code

Country of Permanent (Home) Address

Permanent (Home) Address of Parent 2 – Father

Street Name and Number

Additional Information about Address (e.g. c/o)

City, Town

State, County, Region

Zip (Postal) Code

Country of Permanent (Home) Address

Permanent (Home) Address of Significant Other, Legal Guardian

Street Name and Number

Additional Information about Address (e.g. c/o)

City, Town

State, County, Region

Zip (Postal) Code

Country of Permanent (Home) Address

Invoice can be made for Child’s Name and Permanent Home Address

Yes

No, Different Billing Name or Address

Billing Address

Billing Party’s Name if different from Child’s

Street Name and Number

City, Town

State, Region, County

Zip or Postal Code

Country of Billing Address

Email Address that you want to use for Urgent and Confidential Communication.

Email of Parent 1 – Mother

Email of Parent 2 – Father

Email of Significant Other

Email Address of Parent 1 – Mother

Email Address of Parent 2 – Father

Email Address of Significant Other

Telephone that you want to use for Urgent and Confidential Communication.

Telephone of Parent 1 – Mother

Telephone of Parent 2 – Father

Telephone of Significant Other

Parent 1 – Mother’s Mobile Phone number with Country Code

Parent 1 – Mother’s Local Phone/Mobile Number

Parent 2 – Father’s Mobile Phone number with Country Code

Parent 2 – Father’s Local Phone/Mobile Number

Significant Other’s Mobile Phone number with Country Code

Significant Other’s Local Phone/Mobile Number

I have read and agree to the Terms and Conditions and Privacy Policy. I particularly agree that no refunds may be given for cancelled services or in cases when the patient and parent (caregiver) were not available for the requested services, according to the Payment Terms and Conditions.

Other Important Information you would like us to know. Optional field.

Additional File Upload – Optional (Insurance Policy, Medical Records, etc.)

Choose File (pdf, jpeg, jpg, png, bmp, gif)

Email Address to confirm Data Form Submission

Signature of Parent or Caregiver – Type your full name here as the first step to confirm your Identity. IMPORTANT! After you Submit the Form here you have to open the message sent to your Email and Click on the “Confirm Submission” Button.