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    • Registration Documents
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  • LEARN MORE
    • Accepted Insurance
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    • Locate / Contact
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NEW PATIENT REGISTRATION

Registration DocumentsMichael Linck2017-01-23T11:46:48-06:00

Step 1 of 12 - PATIENT INFORMATION

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  • First NameLast Name 
  • I agree to pay all charges, in full, once they have been processed by my insurance company, if any balance remains due. Below are the most common procedures and tests that may be applied toward your insurance deductible. These costs are approximate and will vary based on your insurance company. These charges are in addition to the office visit charge.

    - Earwax Removal $65 - $75
    - Lesion/Wart Destruction $125 - $175
    - Sutures, Staples or Skin Glue $125 - $225
    - Abscess Care $150 - $180
    - X-rays & Radiologist $25 - $39
    - Splinting $50 - $95
    - Breathing Capacity Test $19
    - Flu Test A $15
    - Flu Test B $15
    - Strep Test $15
    - RSV Test $9
    - Mono Test $7
  • Phone Number (000-000-0000) 
  • STOP! Non-immunized individuals pose an extreme health risk to newborn children because newborns are unable to receive immunizations until 2 months of age. Please ask for assistance.

  • Please see a reception desk employee to obtain an authorization code.
  • My physician will complete forms and prescription refills during my visit at no charge. All forms requiring medical review and a physician's signature without a visit, will incur the following charges:

    - FMLA, Disability or Complex Forms - $29
    - Asthma Action Plans - $19
    - Allergy Plans - $19
    - Sports Physical Forms - $19
    - Day Care/School Attendance Forms - $9
  • Once your insurance claim is final, we will automatically charge your card for any outstanding balance. You will receive an email receipt with details regarding the charge.

    CCOF Authorization
    I, the Cardholder, do hereby authorize Pediatric People PLLC to charge my credit card all charges not covered by my insurance company. This agreement shall remain in effect until the specific credit card expires, or until revoked by written notification from me, or at the discretion of Pediatric People PLLC.
  • (Must be between 8-20 characters.)
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