New Teen Patient Registration

Please correct the errors described below.

INSURANCE INFORMATION - POLICY HOLDER

Policy Holder's Name

PRIMARY

SECONDARY

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.

Please be advised that all co-pays are due at the time of service. If collection should ever be required on your account, collection expenses will be incurred by the responsible party.

Your information will be encrypted.

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