Uptown Pediatrics Patient Registration [DOB Last Name: Name Phone: DOB [DOB Specialist PT Primary Care Doctor (Name: Hospital Patient(s) Born In ... DOB: Apt City Phone# Phone# State Z Patient lives with: ( ) Both Parents ( ) Parent I ( ) Parent 2 ( ) Other Portal Email Address: ( ) Parentl ( ) Parent 2 ( ) Patien (By providing my email, I give ....