Patient Registration

Please correct the errors described below.

PEDIATRICS

Siblings:

Add sibling(s)

Best Number to Reach You:

Add another number

Emergency Contact (other than child's parents)

Preferred Pharmacy

Consent for Treatment of a Minor

This is to authorize and consent to any necessary or routine medical or surgical treatment including examination, injection, immunizations and/or diagnostic procedures, including X-ray or lab tests. I understand that only myself or those listed below will have the authority to authorize treatment

Add another authorized person(s)

Any person bringing the patient in for treatment not listed above must have a letter of consent from me or treatment could be refused or delayed. I understand that efforts will be made to contact me prior to the rendering of treatment, but that medical treatment will not be withheld if I cannot be reached.

Assignment of Benefits

I authorize direct payment of surgical/medical benefits to Mark G. Gilchrist, MD, LLC for services rendered by him or any health care provider working in this office. I understand, and agree that I am financially responsible for any balance not covered by my insurance and agree to pay the balance.

Authorization to Leave Messages

This authorization will remain in effect unless so designated, in writing, until the child is no longer a patient of this practice.

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.

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