Forms

Consent For Care

There may be times where you are unable to bring your child in for a visit. This form allows you to designate other family members, caretaker, or other person to bring your child in for a visit. We will not be able to see your child if they are brought in by someone that is not on a signed consent form or the initial intake paperwork.

Authorization Of Credit Card

Because of the ever changing insurance policies and more plans transferring costs to the policy holder with high deductibles and large copays, a credit card must be kept on file. A credit card authorization form must be kept on file for all patients in the practice.

Release Of Records

A signed release is required to be on file anytime a request is made for copies of a patient record. We cannot release records to anyone until a release is signed.