PATIENT REGISTRATION

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Parent Responsible for Payment:

(this will be kept secure and will not be shared with any other offices/companies)

Medical Insurance Information

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I authorize payment of medical benefits to my physician for professional services rendered. I authorize the release of any medical information to my insurance company.

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.

Person to contact in case of an emergency other than parent

If I am unavailable, I request The Pediatric Center, or any physician they may delegate, to give any and all medical or surgical care to the above named children. This includes my permission for the children to be admitted to a hospital and for the performance of surgery and anesthesia as deemed advisable by the above named physicians or their delegates.

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