Our goal is to provide and maintain good physician-patient relationships. Letting you know in advance of our office policies allows for a good flow of communication and enables us to achieve our goals to provide the most comprehensive healthcare for your children. Please read each section carefully and sign at the bottom. Upon completion, return the signed “Authorization” page to the receptionist. The copy of the policy is yours to keep. If you have any questions, please do not hesitate to ask a member of our staff.
A $10 form fee will be charged for ALL forms that parents/patients request to be filled out by a physician or nurse. Payment for the forms must be made before the forms are processed by the office. Forms will only be accepted for completion if the sections that need to be filled out by the patient or parent are already completed.
Forms can take as long as 2 weeks to complete particularly in the spring and summer. You will be called when the forms are completed and the forms will be waiting at the front desk. “Rush” jobs will be completed within 48 hours for an additional $10. If you would like your forms mailed to your home or another address, you must include a self-addressed stamped envelope. Only accounts that are in good standing and patients with current physicals (within 12 months of the time the form is being completed) will be processed.
Financial Responsibility: Please be aware that before we can offer you an appointment time for any visit, prior balances must be paid prior to the visit.