Young Pediatrics
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Emergency Contacts, other than parents: Name & Relationship
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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):
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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.
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