NOTIFICATION SHEET

Please correct the errors described below.

PATIENT(S):

First Name:

Last Name:

First Name:

Last Name:

First Name:

Last Name:

WHAT IS THE BEST PHONE NUMBER TO REACH YOUR FAMILY?

Cell Home

Phone Number:

APPOINTMENT REMINDERS:

Email Text Message Phone Call

Please input the information needed for your selected appointment:

DUE FOR AN APPOINTMENT (WELL CHILD CHECKS, VACCINES):

Email Text Message Phone Call

Please input the information needed for your selected appointment:

Billing statements are sent to the address on file of the financial guarantor.

ARE YOU SET UP ON OUR PATIENT PORTAL? Do you know your password? (If you need it reset, ask us!)

THE PATIENT PORTAL ALLOWS YOU TO CONFIRM AND REQUEST APPOINTMENTS, PAY YOUR BALANCE, PRINT IMMUNIZATION RECORDS, UPDATE PATIENT AND PARENT INFORMATION, AND REQUEST PRESCRIPTION REFILLS.

YES, I AM SIGNED UP NO, SIGN ME UP!

EMAIL:

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