**If you have any changes of Coverage through the year, please notify us immediately**
Changes may affect where lab work or tests are done. You are responsible for knowing the terms of your contract with your insurance company. If you insurance has co-pay, please make payment upon arrival.
In order to produce a proper insurance claim of any visit, the following MUST be filled out:
List any other children that may also come to the practice:
Your information will be encrypted.
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