Patient Information Form

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Guarantor Information

Emergency Contact

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Pediatric Specialists of Tulsa to release any information required to process my claims.

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

Insurance Information

Contact Preferences

**PLEASE NOTE: The choices below are how you will be contacted. If you only want one person contacted please be sure to note that. If both are chosen we will send reminders and messages to both parents.

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