Patient & Family Information

Please correct the errors described below.

**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:

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