New Patient Form

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FAMILY INFORMATION

Thank you for choosing our office. In order to serve you properly, we need the following information. Please fill out this form completely.

Preferred method for appointment reminder (please enter number or email):

CHILDREN

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PARENT

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OTHER PHONE NUMBERS

INSURANCE INFORMATION:

ELIGIBILITY WAIVER:

Parents are expected to attend all wellness visits until patients reach the age of 18. During the first 3 years of life, we see infants for routine well childcare at: 1 month of age, 2 months of age, 3 months of age, 4 months of age, 5 months of age, 6 months of age, 7 months of age, 9 months of age, 12 months of age, 15 months of age, 18 months of age, 2 Years of age, 2 ½ years of age, 3 years of age, and annually thereafter. Please verify that your insurance company provides full coverage for these visits prior to the visit. If it is determined that I am not eligible for coverage, I understand that I will be responsible for payment of all services provided.

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