Patient Demographic Information

Patient's Name

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Cell Phone

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Insurance

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Authorization for Treatment and Release of Information

I authorize Poole and Thomas Pediatrics to evaluate and treat me and to release to my insurance company any information acquired in the course of my examination or treatment, and to receive all payments for such examination or treatment, Poole and Thomas Pediatrics has my permission to release any diagnostic studies, reports, etc. to a specialist involved in my care.

Acknowledge of Receipt of Consent to Use and Disclose Health Information

I acknowledge that I have received the Consent to Use & Disclose Health Information, which explains how my health information will be handled in various situations

ATTENTION

Though you may still be covered under your parent’s insurance, you, as an adult, are solely financially responsible for any and all payments: copay, coinsurance, or deductible that your insurance deems as your responsibility.

My signature below indicates I am the patient listed above, that I have provided accurate information to the best of my knowledge and I understand and agree to the provision above.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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