Patient Registration Form

Pediatric Care North

Please correct the errors described below.

Female Parent(s) of Guardian(s) Information

Male Parent(s) of Guardian(s) Information

Health Insurance

Health Insurance

I authorize Pediatric Care North to release any and all medical records, pertaining to my child's health, to my insurance company for any requested additional information.

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

Consent of Treatment

The physicians of Pediatric Care North have my permission to provide my child/children with any necessary treatment. The following persons have my permission to seek medical attention for my child/children in my absence.

By typing your name above, 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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