2023 Patient Registration

Please correct the errors described below.

Patient Information:

Siblings Information

Additional Sibling Information

Primary Guardian/Financially Responsible

Other Parent/Guardian Contact Information

Primary Insurance Information

    Please upload a file

    If yes please list below:

    Consent To Treat

    the parent or legal guardian of the below named child(ren).

    Add new row

    I hereby authorize and consent to the examination/treatment of my child(ren) during the office and facility visits by the physician and clinical staff of Poole and Thomas Pediatrics. In addition, I give permission for the following person(s) to bring my child to Poole and Thomas Pediatrics in my absence and to act on my behalf in authorizing medical care and treatment.

    Until we are notified in writing, Poole and Thomas Pediatrics will assume that a child’s biological and/or legal parents are both legal guardians who have access to treatment options and medical information for that child.

    Additional Information

    Anyone not mentioned above who brings your child into the office for treatment must have a signed authorization from the child(ren)'s legal guardian.


    Thank you for choosing and entrusting Poole and Thomas Pediatrics for your child(ren)’s care. Drs. Poole, Thomas, Crowley and Goodsell are dedicated to providing excellent care to your children at a fair and reasonable rate. In order to provide this care, we have adopted the following financial policy. We recognize that the cost of health insurance has increased; unfortunately, our costs to provide that care have risen significantly as well.

    It is our goal to eliminate future misunderstandings in regards to our billing and payment policies. Our staff will be happy to discuss any fees or financial issues in advance or at the time of your visit. We participate with most major insurance plans. While we will work with you to submit your claims to your insurance company, please note that ultimately your insurance is a contract between you and your insurance carrier. Each insurance policy is individual and it is your responsibility to understand your benefits, eligibility dates, and what is and is not covered by your plan. If claims are not paid within 90 days, the unpaid balance becomes the responsibility of the parent/guardian. We will make every effort to work with you to file insurance claims and resolve any outstanding balances in a timely manner.

    Please be aware that you MUST provide updated demographic (address and phone numbers) and insurance information to our office. Up-to-date information is needed for both parents. We must have a current copy of your insurance card on file at all times. If your insurance changes, it is your responsibility to let us know as soon as possible, along with the effective dates of your new policy. If previous visits need to be re-filed to a different insurance, you must notify us immediately due to Timely Filing requirements by your insurance company. If you do not provide us with the correct insurance information at the time of the change, then your claims may be denied due to timely filing by your insurance and those claims would then become your financial responsibility. You will also be responsible for any denied charges due to incorrect information.

    Co-pays, Co-insurance and Deductibles will be expected at time of service. Private Pay Patients are expected to pay in full at the time of service. If there is an outstanding balance on your account and you are being seen in the office, the balance will be required to be paid in FULL at time of service. NO EXCEPTIONS. In the event of a separation/divorce, the parent bringing the child for an appointment is responsible for the co-pay or balance, which is due during that visit to our office. If one parent specifically is responsible for medical bills, we must be notified of that by both parties. Whichever parent/guardian signs this form, you will be held responsible for any amount owed and it will be your responsibility to collect from the other party.

    Returned Checks: There will be a returned check fee of $50 for any check.

    Weekends and After Hours: There is an additional fee for appointments on late evenings, weekends, and holidays that may or may not be covered by your insurance. Any unpaid charges will be your responsibility.

    Payment: We accept cash, check, debit cards, Visa, MasterCard, Discover, and money orders. Our staff or billing office may contact you at any of the numbers provided by you in an attempt to resolve any outstanding balances.

    You can expect to receive one billing statement from our billing office and payment is due within 30 days. If you have not made a payment within 30 days from receipt of the statement, you will receive a letter asking for payment. If we do not hear from you at that time, your account will be turned over to a professional collection agency. This will result in termination of the physician/patient relationship.

    Assignment of Benefits/Authorization: As parent or legal guardian, I authorize payment of medical benefits directly to Poole and Thomas Pediatrics, PLC for services rendered. I further agree to be fully responsible for all lawful debts incurred for these services.

    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.


    At Poole and Thomas Pediatrics, we are committed to protecting the security and privacy of your child’s personal information. Medical records are the property of Poole and Thomas Pediatrics. These records are kept in a secure location, and are accessed only for the purposes outlined by the Notice of Privacy Practices (Revised 9/23/13). Our revised Privacy Notice is available at www.ptpediatrics.com , or you may request a copy from our office. Records may be released or shared with other healthcare professionals for the treatment of your child. Patients are entitled to one free copy of their medical records only after an authorization for release is signed. Additional copies may be made for a fee of $1.00 per page, per KY House Bill 250.

    • By signing below, I acknowledge that I have received Poole and Thomas Pediatrics Notice of Privacy Practices and consent to treat information. I understand that I can edit any of the terms below. I understand that PTP may call my home and place of employment for healthcare reasons, appointment reminders, to resolve billing issues, and may mail me information postcards to my home address. PTP may also mail bills to my mailing address.
    • I understand that PTP may leave messages on my answering machine regarding appointments and limited lab information.
    • I understand that PTP may use an email address, text messaging or fax, provided by me to communicate appointment information, billing issues, immunization certificates, lab and test results, and other forms requested by the parent.
    • I authorize PTP to email or fax immunization certificates and/or school forms, or to mail to my home address provided.
    • I authorize PTP to discuss patient information with adults or other minors present during the visit regardless whether I am present.
    • I understand that if I send a picture of myself or child(ren) PTP may display it within the office.

    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.

    Your information will be encrypted.