Policy and Procedure Form

For the benefit of patients, this office provides this statement regarding its operating policies and procedures:

1. This office maintains strict standards of confidentiality. However, be informed that in cases of sexual or physical abuse of a child, or where a person’s life is in immediate danger, we are obligated by law to report such circumstances to the appropriate authorities.
2. All requests for release of patient records must be authorized by the patient/legal guardian in writing. We have the necessary authorization forms.
3. Fees for professional services are due at the time the service is rendered unless prior arrangements have been made in writing. Fees must be paid either in cash or by check. No services will be provided for patients who have outstanding fees.
4. Patients are expected to call to cancel appointments with at least 24 hours’ notice. Please note that if an appointment is cancelled with less than 24 hours notice, the patient will be billed for the amount of time that had been reserved for him/her. There are of course, perfectly valid reasons for occasional cancellations (e.g. illness). However, the charge will apply unless another client is willing on short notice to switch to your appointment time.

I have read and understood all of the above statements. I consent to be evaluated and treated, or have the child named below evaluated or treated by Juandalyn Peters, M.D.

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.