to attend ill OR well visit appointments alone, without the presence of a legal guardian or authorized adult. I authorize treatment for my child in accordance with the policies of Bloomington Pediatrics, LTD. This includes providing a history of present illness, disclosure of protected health information, and responsibility for relaying any diagnosis, treatment plan, forms or prescription(s) to the parent or legal guardian mentioned above. I agree to be available by phone and to be financially responsible for all copays, deductibles and/or coinsurance resulting from the visit.
Currently prescribed or over-the-counter medications and dosages:
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If Insurance information has changed, please complete the following and plan to send the card with your child for scanning into their record.
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