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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.


Parent or Guardian preference regarding communication of health information. I herby give permission for the following people to obtain medical care for my child.

Family Profile

Past Medical History

breathing, antibiotics, heart problems, ect


Family History

Do any family members have a history of?

* Required field