Please complete and return to our office at least 2 business days before your scheduled appointment
Please correct the errors described below.
Parent #1/Legal Guardian(Primary):
Parent #2/Legal Guardian(Secondary):
Emergency Contact (Other Than Parent):
Insurance card(s) must be presented at every visit to process claims
*Guarantor= The person who holds the insurance. Please let us know if bills should be mailed to a different address.*
I hereby authorize my insurance benefits to be paid to Pediatrics at Newton Wellesley, PC and acknowledge that I am responsible for any balance not covered by those benefits. Delinquent accounts will be submitted to a collection agency, and any collection fees will be the parent/guardian/guarantor's responsibility. In cases of divorce or separation, unless otherwise specified by a court order, both parents will be permitted to bring the child(ren) into the office and have full access to your child(ren)'s medical records.