Patient Registration

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Patient Information:

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Additional Sibling Information

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Additional Parent/Legal Guardian Information

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    Please be aware that our Financial Policies are available on line at www.ptpediatrics.com or you may ask for a copy in the office. By signing below, I authorize medical treatment and payment of medical benefits for any services rendered by Poole and Thomas Pediatrics, PLC. I assume all responsibility for charges and authorize the release of any medical information needed to process any claim. I permit a copy of this authorization to be used in place of the original.

    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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