NEW PATIENT - APPLICATION FORM - Currently only accepting Children younger than 1 Year old

BRIGHTSTARTS PEDIATRICS PC

256-461-8442

Patient Information : Last Name

First Name

Date of Birth

Current Mailing Address (No PO Box)

City

State

Zip Code

Patient - Medical History (provide details of all chronic conditions including all Mental Health conditions)

Current Medications (list all current prescription medications including Psychiatric medications))

Vaccine Policy: Brightstarts Pediatrics providers do not accept patient families unwilling to adhere to CDC and ACIP recommended vaccines

Patient will be taking all school required vaccines.

Yes

I have a copy of the patients vaccine record? (a copy will be required before your first appointment)

YES

List all siblings that are currently patients at Brightstarts Pediatrics

Primary Health Insurance

Secondary Insurance

NEW PATIENT - MISSED APPOINTMENT

$35.00 administrative charge will apply for missing this FIRST appointment, without a 24hr cancellation notice. These charges will be your responsibility and billed directly to you.

NO SHOW POLICY

If for any reason you are not able to keep your appointment, please let us know immediately so others may be seen and keep our wait time to a minimum. Frequently missing scheduled appointments without a 24hr cancellation notice will result in your child's dismissal from our practice.

PAPERWORK

Paperwork completion i.e., sports/camp forms, medication forms, daycare forms etc. will be completed within 48-72 hours. FMLA Forms and letters written by the physicians will incur a $25 charge and will require 48-72 hours.

NON-ROUTINE PRESCRIPTIONS

There will be a $25 charge for prescriptions provided without an office visit

ROUTINE REFILLS

(a) All Psychiatric medication refills, including ADHD, Anxiety, Depression etc. require a recheck every 3 months (b) All other routine refills including asthma, eczema, allergies, thyroid medication etc. will require a recheck every 6 months

DIVORCED OR SEPARATED PARENTS

BRIGHTSTARTS PEDIATRICS providers and staff will not become involved in disputes between family members. Should a dispute interfere with your child's healthcare, or should an issue become disruptive to our practice, we will discharge the patient from further treatment.

FINANCIAL RESPONSIBILITY

It is your responsibility to bring your insurance card with you to every visit and be prepared to pay your copay and/or deductible as well as any past balance at each visit, regardless of who brings the child in for the visit.

ACKNOWLEDGEMENT

I have read and agree to all the policies listed on this form

Name of person signing this form

Relationship

Date Signed

Cell Number

Parent Email Address

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