Assignment of insurance benefits and authorization to release information

Please read and initial each section of our financial policy. It is important that you understand this prior to establishing your child(ren) as patient(s). If you have any questions regarding this policy, please call our office and ask one of our receptionists.

Please complete as much of this medical history form that applies to your child. Family history is on page two and should also be completed.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Vaccine Agreement – This form is required by all new patients. Great Kids Pediatrics does not alter or delay the recommended vaccination schedule.