New Patient Form

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Patient Information:
Parents Information and Emergency Contact:

Primary Insurance Company
I give permission for the following people to seek medical care, on my behalf, for the above listed child
Only the following listed people will be permited to obtain information regarding my child
- I Consent to treatment as necessary or desired for the above-named patient, including but not restricted to whatever drugs, medicines, procedures, laboratory, X-Ray, or other studies that may be used by the attending Doctor or his/her qualified designate. -  I, also, acknowledge full responsibility for the payment of such services at the time of service unless other arrangements have been made. I understand that my insurance carrier is being billed as a courtesy to me, but should they not pay for these charges I understand that I will assume full financial responsibility. - I authorize the release of any medical or other information necessary to process the insurance claim for services provided to my child. - I also authorize any payment due from my medical insurance to be paid directly to Little Buddies Pediatrics PA. dba Pediatrics of Sugar Land