REGISTRATION FORM

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PATIENT INFORMATION

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INSURANCE INFORMATION

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ASSIGNMENT AND RELEASE

I the undersigned certify that I (or my dependent) have insurance coverage as above and assign directly to Pediatric Health & Wellness all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

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PRIVACY POLICY

At Pediatric Health & Wellness we are committed to ensuring patient privacy and confidentiality. Please sign below to indicate that you and the responsible party have had an opportunity to read and understand our privacy policy.

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CONSENT TO CALL – AUTHORIZATION TO RECEIVE AUTOMATED PHONE CALLS

We use an automated telephone system for appointment reminders and other information from time to time. Please sign below to authorize us to contact you via our automated phone call system.

I consent to receive automated phone calls from Pediatric Health & Wellness:

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