Well Child Visit
First & Last Name
Patient Date of Birth
Each child and family is unique; therefore, recommendations for Preventative Pediatric Health Care are designed for the care of children who are receiving competent parenting, have no manifestations of any important health problems, and are growing and developing in a satisfactory fashion.
Additional visits may become necessary if circumstances suggest variations from normal. If these variations do occur during my visit and are addressed outside the scope of the Well-Child comprehensive health guidelines, I may incur additional charges. These concerns may include, but are not limited to, procedures, recommendations, treatments and/or consultations of medical conditions.
If portions of my Well Child visit and/or physical examination are not covered by my insurance company, I understand that I will be responsible for any charges not covered, including copayments, deductibles, co-insurance and fees for non-covered services. These non-covered services include, but are not limited to, vision, hearing tests, developmental screenings, etc.
Although the billing department will provide assistance with any insurance processing, it is my responsibility (parent/guarantor) responsibility to understand my insurance benefits and coverage.
First & Last Name
MCHAT-R Developmental Screening
Please answer these questions about your child. Keep in mind how your child usually behaves. If you have seen your
child do the behavior a few times, but he or she does not usually do it, then please answer no. Please select yes or no
for every question. Thank you very much.
Please note that we may change your appointment from a wellness exam if the patient is sick or has multiple or severe concerns. <br/><br/>Type N/A if no additional concerns
Thank you for completing this form.
