Pediatric Specialists

Yearly Patient Registration Form

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Parent(s) or Guardian(s)

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Patient 18 Years or Older:

Insurance Information

I authorize payment of medical benefits to the physician or supplier of Pediatric Specialists of Foxborough & Wrentham for services rendered during my child(ren)'s exam or treatment. I also authorize my child(ren)'s physician to release any information acquired in the course of their exam and/or treatment to my insurance company to determine these benefits or the benefits payable for related service. If for whatever reason, my insurance does not pay for visits, I will be responsible to make payments.

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