New Patient Packet

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PATIENT INFORMATION

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Primary Contact

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I give permission for the following person(s) to bring my child/children to Growing Together Pediatrics to receive medical treatment and be included in their care in my absence.

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DISCLAIMER: 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.

To assist us in obtaining previous medical records please provide the following information

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If child is less than 5 years old or if there was a significant/complicated pregnancy history

Pregnancy/Birth History: Fill all that apply

Birth/Newborn Complications

This Child has been DIAGNOSED with

Child’s Hospitalizations

Directions: Please click relationship M=Mother, F=Father, S=Sibling(s), GM = Grandmother, GF=Grandfather, O=Other Relative(s)

Diagnosis of relative

Social/Environmental

CONSENTS AND ACKNOWLEDGEMENTS

Please read each item and sign below

Consent to Treat

I have the legal right to consent to medical and surgical treatment for this patient. I voluntarily authorize and consent to such medical care, treatment, and diagnostic tests that the clinic and its licensed medical providers and designees consider necessary. I understand that no warranty or guaranty has been or will be made as to the result or cure from treatment. I understand that by signing this form, I am giving permission to Growing Together Pediatrics and its providers to administer treatment to this patient for as long as they are an under the care of Growing Together Pediatrics or until I withdraw my consent.

Immunization Policy

I have reviewed the “Growing Together Pediatrics Immunization Policy”

Financial Policy

I have reviewed the “Growing Together Pediatrics Financial Policy”

Electronic Prescriptions (E-Prescribing)

I authorize E-Prescribing for prescriptions. This allows health care providers to electronically transmit prescriptions to the pharmacy of my choice, review pharmacy benefit information and medication dispensing history as long as a physician/patient relationship exists.

Acknowledgments

I acknowledge that administrative data, demographic information and other health information describing patient care, services and outcomes are collected and used for healthcare operations, governmental and nongovernmental reporting, and comparisons with other providers. In some instances, performance data is aggregated and reported per physician. In every instance, we make every reasonable effort to maintain patient and physician anonymity.

Imaging

I consent to the taking of photographs or films related to the care and treatment and understand that such photographs or films may be made part of the medical record and / or used for internal purposes such as performance improvement or education.

Notice of Privacy Policies

I have had the opportunity to review the “Notice of Privacy Policies” detailing how my information may be used and disclosed as permitted under federal and state law. I further understand that I have the right to request restrictions as to how my health information may be used or disclosed and that the organization is not required to agree to these restrictions.

Payment of Services

I understand that all co-pays and deductibles are to be paid at the time of service. In the event that my account becomes delinquent and must be turned over to a collection agency or attorney, I agree to pay any and all costs of collection including attorney’s fees. I understand that my insurance policy is a contract between myself and my insurance company and that I am financially responsible for charges not covered by the policy. I will assist in the collection of my insurance benefit should there be any delay in payment.

DISCLAIMER: 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.

PEDIATRIC COMPREHENSIVE PATIENT HISTORY

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