Patient Information Form

Please correct the errors described below.

Alternate Contact

Primary Insurance

Secondary Insurance:

Tulsa Pediatric Urgent Consent And Signature

Consent To Treat

I have the legal right and responsibility to obtain and consent to medical and surgical treatment for this patient.

I voluntarily authorize and consent to such medical care, treatment, and diagnostic tests that Tulsa Pediatric Urgent Care Providers believe are necessary for this child. I understand that by signing this form, and by bringing this child to this medical office for care, I am giving permission to the doctors and other health care providers treatmentto this patient as long as he/she is a patient of this practice.

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Credit Card on File Authorization

I agree to place my credit card on file to be run by Tulsa Urgent Care Clinic once the insurance claim has been adjudicated for any additional patient responsibility amounts that has not been credited to my account.

On the day that we receive your adjudicated claim from insurance, we will call and cite the patient responsibility amount that has been assigned by insurance to you. You have provided one number above for us to reach you on. If we do not reach you on the number provided, we will leave a message. If we do not hear back from you by 9:00 Pm, we will run your transaction that afternoon before close of business (which is 11pm weekdays, 10pm weekends). A receipt will be emailed to the email provided above.

authorize Tulsa Pediatric Urgent Care Clinic to run my credit card for the purpose(s) stated above,

*Authorizing signature must match name on credit card.

Please Read. We will be utilizing the services of Instamed, a third party vender for credit card transactions. Instamed stores your information on a separate and secure site. Office personnel will not have access to your card, and only the last 4 digits of your card will be viewable in our system. Instamed is certified as a Level One Service Provider with the Payment Card Industry (PCI) Data Security Standard, as well as the VISA cardholder Information Security Program (CISP). They are audited and scanned for PCI compliance and is regularly scanned for vulnerabilities by ScanAlertT and is a member of their HACKER SAFE program.

Your information will be encrypted.