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Available Forms

New Patient Information

Child Information

Last, First, MI
City, State, Zip

Parent Information (Mother, Father, or Legal Guardian) - REQUIRED

City, State, Zip
 
City, State, Zip
 
Name and Phone #
 

Insurance Information

This is a direct assignment of my rights and benefits under this policy, I agree to pay charges not paid by insurance. A photocopy of this agreement shall be considered as effective and valid as the original. I also authorize the release of any information pertinent to my case to any insurance company , adjuster, or attorney involved in this case. I have received a copy of HIPPA (Health Insurance Portability and Privacy Act)and agree to the policy.

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