Pediatric Associates of Denham Springs

Patient Information

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PATIENT INFORMATION

Patients Name

PARENT/GUARDIAN INFORMATION

INSURANCE INFORMATION

CONSENT

My signature below authorizes the following person(s) to bring my child in for medical care, pick up prescription/forms, or to discuss my child's medical care.

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✓ I give my permission for Pediatric Associates of Dental Springs to treat my child according to the standards of care within the community & the realm of medical necessity as deemed appropriate by his/her physicians.

✓ I give my permission for Pediatric Associates of Denham Springs to obtain my child's e-med history.

✓ I give my permission for Pediatric Associates of Denham Springs to send text message reminders.

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

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