New Patient sign up for Pediatric Clinic LLC

PLEASE FILL OUT ALL FIELDS COMPLETELY

I acknowledge that I will be financially responsible for all services rendered to my minor child. I also acknowledge that in the State of Alabama, both parents are both, separately, 100% financially responsible for the healthcare expenses of their minor children regardless of any divorce decree or any other agreements unless parental rights have been terminated.

First & Last name of Parent / Guardian on the account:

Social Security Number of Parent/Guardian

Parent/Guardian Date of birth

Relationship to Patient (e.g. mother, father, guardian, etc.) :

Cell Phone Number

Home Phone Number

Work Phone Number

Email field

Full Street address

City State Zip Code

Other Parent /
Guardian:

First & last name of other Parent / Guardian:

Relationship to Patient

Social Security Number of other Parent/Guardian

Date of birth of other Parent/Guardian

Full Street address (if different than above)

City, State, Zip (if different than above)

Cell Phone Number

Work Phone Number

Child - First Name

Middle Name

Last Name

Sex - male or female

Child 1 - Date of birth

Emergency Contact, Phone Number and Relationship

Emergency Contact, Phone Number and Relationship (2)

I agree to the terms of service as stated above.

Electronic Signature - by signing below, I agree to the terms of service listed above.

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