patient forms

patient information

Male   Female

parent/guardian information

account information

primary insurance

secondary insurance

medical history

Please check any conditions your child has or previously had.

HIV
Blood Disease
Blood Transfusion
Cancer
Convulsions
Diabetes
Ear Disorders
Epilepsy
Eye Disorders
Heart Condition
Hemophilia
Hepatitis
High Blood Pressure
Hormone Disorder
Hyperactivity
Jaundice
Kidney Disease
Liver Disease
Leukemia
Lung Disease
Mental Retardation
Muscle Disorder
Nose/Throat Disorder
Prolonged Illness
Rheumatic Fever
Skin Disease
Speech Problems
Stomach Problems
Tuberculosis
 
Yes   No Yes   No Yes   No Yes   No
 



PLEASE REMEMBER THAT INSURANCE IS CONSIDERED A METHOD OF REIMBURSING THE PATIENT FOR FEES PAID DIRECTLY TO THE PROVIDER AND IS NOT A SUBSTITUTE FOR PAYMENT. INSURANCE IS FILED, ON THE DATE OF SERVICE, AS A COURTESY TO OUR PATIENTS AND THEIR FAMILIES. IT IS THE PARENT'S ULTIMATE RESPONSIBILITY TO PAY THE DEDUCTIBLE AND ANY OTHER BALANCE, NOT PAID BY THE INSURANCE COMPANY, ON THE DATE OF SERVICE. WE WILL ALLOW 30 DAYS FOR YOUR INSURANCE TO PROCESS OUR SUBMITTED CLAIM AND MAKE PAYMENT ACCORDINGLY. IF PAYMENT IS NOT RECEIVED WITHIN THE TIME FRAME SPECIFIED ABOVE, WE WILL BILL YOU FOR DELIVERED SERVICES. BILLING IS DONE AS A COURTESY TO T HE PATIENT AND IS NOT A RELEASE OF FINANCIAL RESPONSIBILITY FOR THE PARENT/GUARDIAN.