Registration Form

Add Child(ren)

Address:

City:

State:

Zip Code:

Email address

Parents Names:

Mom's Name:

Home Phone

Cell Phone

Work Phone

Dad's Name:

Home Phone

Cell Phone

Work Phone

Preferred Language:

Insurance Name

Policy#

Group#

Guarantor (person who holds the insurance)

Name

Date of Birth

SSN

Address & Phone (if different)

PCP

Dr. Milana Stavitsky Dr. Rosina Mele Dr. Sarah Kachan-Liu

I hereby give permission for my doctor to bill my insurance for all appropriate services:

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

Signature:

Date

I understand that I am liable for all charges not covered by my insurance:

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

Signature:

Date

Your information will be encrypted.