Patient Registration Form

Please correct the errors described below.

Mother's Information (Or Guardian)

(If different than father's address)

Father's Information (Or Guardian)

(If different than mother's address)

INSURANCE

INSURANCE

LIST ALL CHILDREN IN FAMILY WHO ARE PATIENTS IN OUR OFFICE:

Add another child

Emergency Contact: (Not Parent)

Authorization to Treat: There may be occasions when a parent (guardian) is not available to bring your child(ren) to our office. Your signature below allows us to provide care for your child(ren) in your absence. Otherwise, we need written permission prior to caring for your child(ren) for each occurrence.

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

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