Smita Parikh Mengers, MD FAAP & Wendy R. VanBronkhorst, MD FAAP
**All information must be filled out completely**
Primary Insurance
Secondary Insurance
By initialing below, I indicate that I have received a copy of Dr. Smita Parikh Mengers, MD and Wendy R. VanBronkhorst, MD Notice of Privacy Practices.
Insurance Authorization and Assignment of Benefits
Payment Policy
Please speak to us about any concerns you may have. By communicating how your experience was in our office, you enable us to provide you with the best care possible. Thank you!
By signing below, I indicated that I have read the above policies and agree to the applicable conditions, I consent treatment, financial responsibility and insurance authorization.
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.
Our office is dedicated to providing all our patients with the most thorough and comfortable pediatric care available. We know that efficient scheduling is an important part of the office experience. We appreciate your respect for our daily schedule which allows our staff to be on time for your children. We will always respect your time.
To enable us to provide efficient care we ask for your cooperation with the following guidelines:
We DO NOT accept walk-in appointments, please call and schedule your child’s sick or well visit.
*Parents/Legal guardians MUST be present at any/all well check appointments. **
**This policy applies to all appointments at our office**
Should you no-show for 3 appointments, you may be discharged from the practice.
We feel these guidelines are reasonable in relation to the services we provide. We do understand that circumstances occur that will require consideration.
I understand that I am expected to follow this policy as a patient at this office.
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.
I give authorization to the following individuals listed below to make medical decisions for my child (ren) in my absence (i.e. grandparent, relative, neighbor, babysitter):
These individuals are authorized to take any and all lawful acts, deeds, matters, and things in any way connected with my child’s health care. Such authorization includes, but is not limited to, the giving, refusing, or withdrawing consent to provide professional services on behalf of my child (ren).
This authorization shall remain in full force and effect until one or both of us are available by telephone, in person or otherwise to make health care decisions for my child (ren).
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 information will be encrypted.