Parent 2 Preferred Phone *
Employer Work Address
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Information about your new baby:
OB/GUN or Midwife:
Hospital or Birth Center Delivering at:
Do you have other children that use our office or another pediatrician? If so, list their names and date of births and their pediatrician.:
Emergency Contact Person:
Names of individuals, and relationship, (other than parents) of persons whom I give permission to bring in my child and be responsible for carrying out the directives given to them by Advanced Pediatrics. Please note that the person bringing in the child is responsible for payment.
How did you hear about our office?
OB/Gyn/Midwife Family Member or Friend Saw one of our ads on social media Internet Search (Google etc.) Other Who may we thank for referring you to us?
Insurance Information (you must provide us with a copy of your current insurance card at the first visit)
Name of Insured
DOB of Insured
Insurance provided through:
Employer Private State Self Pay Other Please select one of our physicians as your primary care physician and notify your insurance of the selection.
Name of physician shown on your card:
Authorization of Treatment and Assignment of Benefits: I authorize The Center for Advanced Pediatrics, to treat my child/children. I further authorize the release of medical information necessary for the completion of insurance forms, school & camp forms. I authorize payment directly to The Center for Advanced Pediatrics, for any and all medical or surgical benefits otherwise payable to me under the terms of my insurance. I also affirm that I will reimburse Advanced Pediatrics for any payments my insurance company may have sent to me in error. I understand that I am financially responsible for all co-payments and any charges not covered under my insurance benefits. I also understand that I am responsible for advising Advanced Pediatrics of any and all changes to my insurance. Payment of co-pays are due on date of service. Failure to pay co-pay at that time will result in an additional billing charge of $25.00. Our office requires 24 hours notice of general pediatric appointment cancellation and 48 hours for specialists. Failure to provide this notice will incur a cancellation fee.
By submitting this form you agree to the above and validity of the information.