Pediatric Registration Form

  • Child’s Information

  • Mother/Guardian

  • Father/Guardian

  • Emergency Contact Information (A local person other than Parents or Guarantor)

  • HIPAA Disclosure (People other than parents/guardians)

  • Insurance Information

    (Please provide all the insurances for the child. Not providing all the insurance information will result in the patient being discharged from the practice)
  • Who is authorized to bring the child(ren) for a visit and make medical decisions on their behalf?

  • CONSENT FOR EXAMINATION, MEDICAL TREATMENT AND CONDITIONS OF EXAMINATION

  • INFORMATION CONCERNING FILING A CLAIM WITH YOUR INSURANCE COMPANY

  • AUTHORIZATION TO FILE INSURANCE CLAIMS, TO RELEASE MEDICAL INFORMATION AND ASSIGNMENT OF BENEFITS

  • AGREEMENT AS TO CO-PAYMENTS, NON-COVERED OR NON-PAID SERVICES AND GUARANTEE OF PAYMENT

  • This field is for validation purposes and should be left unchanged.
New Patient
Registration
Patient
Portal
Virtual
Tour