New Patient Paperwork

Please correct the errors described below.

Add another child

Additional Questions:

Primary Insurance:

Secondary Insurance:

If parents are divorced or separated please fill out this section:

Emergency Contacts, Other than parents: Name and Relationship

Add Another Contact

Authorization and Release

I authorize release of my information concerning my child’s health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits, otherwise payable to me, directly to the doctor.

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.

Your information will be encrypted.