New Patient Datasheet

Ambler Pediatrics

Please correct the errors described below.

PATIENT INFORMATION – Please complete all sections

(first, middle, last)

Add new row for another sibling

PARENT/GUARDIAN #1

ADDRESS (if different from above)

CONTACT INFO (only for appointment reminders)

PARENT/GUARDIAN #2

ADDRESS (if different from above)

CONTACT INFO (only for appointment reminders)

I certify that the above information I have furnished is true and correct. I know it is a crime to fill this form with facts I know are false or leave out facts I know are important. (must be signed by both parents/guardians)

DISCLAIMER: By typing your name(s) below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

OTHER PERSONS AUTHORIZED TO ACCOMPANY PATIENTS DURING VISITS (if applicable)

(If you give permission for them to authorize vaccine administration, please indicate below)

FINANCIAL RESPONSIBILITY

(parents/guardians)
(patient's name)

We hereby authorize my child’s insurance company to pay the proceeds of any benefits due me exactly to Ambler Pediatrics. We acknowledge and understand that we are responsible for payment for all the services rendered to any member of our family. Although we have requested the doctor to bill the child’s insurance company on our behalf, we clearly understand that it is still our responsibility to make sure the bill is paid in a reasonable time. If for any reason any portion of a bill is not paid by the child’s insurance company, we further agree to make arrangements for prompt payment of the bill.

MEDICAL RELEASE AUTHORIZATION (must be signed by both parents/guardians)

I authorize release of my child’s records to his/her insurance company, if information is requested with regards to processing claims. I certify that the information I furnish is true and correct. I know it is a crime to fill this form with facts I know are false or leave out facts I know are important.

DISCLAIMER: By typing your name(s) below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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