Patient Pre-Registration Form

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 Information

Insurance card(s) must be presented at every visit to process claims

Primary Insurance

Secondary Insurance

*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.

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