PATIENT REGISTRATION

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Patient Information (Please Print)

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INSURANCE INFORMATION

ASSIGNMENT AND RELEASE

I the undersigned certify that I (or my dependent) have insurance coverage as above and assign directly to Proyouth 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. I hereby consent to the provision of care, diagnosis and/or treatment by Proyouth and I hereby acknowledge that such consent will remain in effect unless and until I cancel such consent in writing.

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

PRIVACY POLICY

At Proyouth 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.

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

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 Proyouth Pediatric Health & Wellness:

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

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