Patient Registration Form

Young Pediatrics

Please correct the errors described below.

Patient Information

Add Additional Child

Contact Information

Add another Contact Person

Emergency Contacts, other than parents: Name & Relationship

Add Additonal Emergency Contact

Additional Contact Questions:

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

The following individuals are able to authorize medical treatment for my child(ren) in my absence:
(If child is 16 and will may drive self and come alone please add his/her name and self as relationship):

Add another authorized person

Collection Clause

In the event the undersigned customer fails to pay pursuant to the terms of this contract Young Pediatrics reserves the right to pursue all available legal remedies pursuant to the laws of the State of Illinois. Should your claim be referred to a collection agency and/or attorney for collections, the customer agrees to pay all necessary fees of collection, along with all legal fees with interest to be accrued at the annual rate of 10 % per annum.

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.

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