Registration Form

Please correct the errors described below.
(Last, First, Middle)
(Last, First)
(Last, First)

Preferred contact method

Children's first and last names and birthdays (oldest to youngest)

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Medical Insurance Information

Primary Insurance

Secondary Insurance

Financial Agreements

Our policy is to collect all co-payments, deductibles, and non-covered benefits in full at the time services are rendered. If at any time you begin to experience a financial hardship, please ask to discuss reasonable payment arrangements with our financial office before services are rendered. If outside collection services become necessary the undersigned agrees to pay all reasonable service charges. I authorize release of any medical information necessary to process my child/children's insurance claims.

In the event that my child/children should require medical and/or surgical treatment and I am unavailable to bring my child/children to Children's Medical Group I grant authority to Children's Medical Group to administer medical treatment to my child/children as they deem necessary. In addition, I grant authority to the person(s) listed below to seek medical treatment for my child/children as they deem necessary, including signing for and approving any and all recommended lab tests, vaccines and other injectable medication.

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