Registration Form

IF YOU ARE A NEW PATIENT OR NEED TO UPDATE YOUR EXISTING REGISTRATION FORM, PLEASE FILL IN THE FORM BELOW.
PATIENT REGISTRATION FORM

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PATIENT REGISTRATION FORM

Please fill forms out completely

Are you a new patient?
How did you hear about our clinic?
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Do you have other children that see our doctors?




I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status. I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims and to any Physician or Health Care Provider to whom my child might be referred for medical reasons. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child.





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