PAYMENT IS DUE WHEN SERVICES ARE RENDERED
INITIAL HISTORY QUESTIONNAIRE
Please list all those living in the child’s home
During pregnancy, did mother
GENERAL DK = don`t know
We will not provide medical care to children whose parents/guarantors refuse to sign and comply with our financial policy. Signature of Understanding: I have read and understand the above stated financial policy.
CONSENT TO TREAT
PRIVACY PRACTICE AND OFFICE PROTOCOL ACKNOWLEDGEMENT
24 Hour Cancellation & “NO SHOW” Fee Policy
By signing below, you acknowledge that you have received this notice and understand this policy.
RELEASE OF MEDICAL RECORDS TO KINGSLAND PEDIATRICS
CREDIT CARD AUTHORIZATION FORM
Please complete all fields. You may cancel authorization any time by contacting us. This authorization will remain in
effect until canceled.
Credit Card Information