Pediatric Specialists

(Leaving Pediatric Specialists of Foxborough & Wrentham)

I understand that as of the date of my signature, Pediatric Specialists of Foxborough and Wrentham is no longer my (child's) medical provider. I will obtain medical care for my child elsewhere.

[In the case of an emergency or illness, we will treat you (your child) for up to 30 days from the date this form is signed, as long as we are still listed with your insurance company as the primary care physician.]

Please fill in the information below, sign, and return this form to the office when you have received the medical records for:

DISCLAIMER: 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.