Patient Demographics

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Patient Registration

Parents/Legal Guardian Information

Mother's Information

Father's Information

Emergency Contact Other than Parents

Responsible Party Billing Address

I hereby assign all medical and or surgical benefits, to include major medical benefits to which I am entitled including Medicare, private insurance, PPO plans and all other health plans to William A. Paruolo. M.D., P.A. This assignment will remain in effect until revoked by name in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information needed to secure the payment. Further, I authorize the provider to provide treatment, including but not limited to examinations, vaccinations, and the dispensing and prescribing of medications. I understand that I always have the right to have an explanation of said treatment and have the right to have any questions answered including the risks and benefits of said treatment prior to receiving any treatment. I also understand that all records will be kept confidential and will remain as such unless a written release is sighed by patient or legal guardian.

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 Child. Your Trust. Our Commitment

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