Patient Information Form


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    The information provided above is complete and accurate to the best of my knowledge. I acknowledge that I have received Cherry Creek Pediatrics’ Notice of Privacy Practices. I have read, fully understand, and agree to all terms set forth in the Office & Financial Policy of Cherry Creek Pediatrics, PC. I assign directly to Cherry Creek Pediatrics all insurance benefits if any, otherwise payable to me for services rendered. I understand that some or all of the services provided may not be covered by insurance for which I may also be billed. I hereby authorize Cherry Creek Pediatrics to release all information necessary for claims administration and evaluation, utilization review, and financial audit. I authorize my child to be treated without me being in attendance.

    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.

    Past Medical History

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