Name: Pediatric People
Price range: $

Hidden

Authorization

BEGIN REGISTRATION

How many children are you registering?*

PATIENT 1

Patient 1 Name*

Patient 1 Date of Birth*

Patient 1 Gender*

Female

Male

PATIENT 2

Patient 2 Name*

Patient 2 Date of Birth*

Patient 2 Gender*

Female

Male

PATIENT 3

Patient 3 Name*

Patient 3 Date of Birth*

Patient 3 Gender*

Female

Male

PATIENT 4

Patient 4 Name*

Patient 4 Date of Birth*

Patient 4 Gender*

Female

Male

PATIENT 5

Patient 5 Name*

Patient 5 Date of Birth*

Patient 5 Gender*

Female

Male

PATIENT 6

Patient 6 Name*

Patient 6 Date of Birth*

Patient 6 Gender*

Female

Male

Mailing Address*

Would you like to get medical records from another office or doctor?*

Yes

No

What is the name of the office or doctor?*

What is their address?*

What is their phone number?*

What is their fax number?*

How should we notifiy you once we are in receipt of your medical records?*

Mail

Telephone

Email

Text

Disclosure of Protected Health Information
I agree to the Protected Health Information Policy outlined below.

Expiration Date of Authorization
I understand that there is no expiration of this authorization. However, this authorization can be terminated at any time at the written request of the patient.

Right to Terminate or Revoke Authorization
I understand that I may revoke this authorization by submitting a written revocation to Pediatric People’s Director of Administration.

Potential for Subsequent Disclosure
I understand that the information that is disclosed under this authorization may be disclosed again by the person or organization to which it was sent. The privacy of this information may not be protected under the federal privacy regulation.

Will you allow anyone, other than a legal guardian, to bring your child(ren) to Pediatric People, PLLC for treatment?*

Yes, I do authorize and consent to Pediatric People PLLC to provide medical treatment to my child without my presence.

No, the above mentioned child(ren) will be accompanied to the office by their parents or legal guardian for all medical treatment.

Authorized Individuals*

First Name

Last Name

By Phone:*

Phone Number (000-000-0000)

Can we leave a voicemail/SMS Message?*

Yes

No

Email*

Enter Email Confirm Email

Immunization Certification*

Yes, I immunize my child according to the immunization schedule established by the Centers for Disease Control and Prevention. I certify that my child is current with ALL immunizations.

No, I do NOT immunize my child according to the immunization schedule established by the Centers for Disease Control and Prevention.

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.

Authorization Code Required*

Please see a reception desk employee to obtain an authorization code.

PATIENT REGISTRATION

PATIENT 1

PATIENT 2

PATIENT 3

PATIENT 4

PATIENT 5

PATIENT 6