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Patient Information (For Members of  the Same family)

Mother/Guardian Information:

Father/Guardian Information:

Responsible Party


Insurance Information

I understand that payment of all medical care is due at the time of service. In case of divorced parents, responsibility and
payment shall be that of the guardian bringing the child in for treatment. I understand that it is my responsibility to pay any
deductible, co-insurance, or any other balance not paid by my insurance company. I understand that I am responsible for any
cost incurred in the collection of patients account in case of default, including reasonable attorney fees and court cost. I
agree to pay any deductibles and any amount not covered by Insurance.

I understand that it is my responsibility to call the office to cancel/reschedule any Well Visits/Yearly Physical, 24 hours
before the scheduled appointment. Failure to do so will result in a “Missed Appointment” fee of $15 per appointment. Copies
of Vaccination Forms (3231) and Hearing/Vision/Dental Forms (3300) after the Annual Physical will cost $5 per form.I understand that insurance companies have agreements with certain laboratories for lab work and that it is my responsibility
to know which laboratory my insurance authorizes and to inform the staff of Sugarloaf Pediatrics as to which laboratory my
insurance covers.

I hereby grant permission to Sugarloaf Pediatrics to release any pertinent information to my insurance company upon request,
and I also assign and authorize payment directly to Sugarloaf Pediatrics. A photo copy of this authorization shall be
considered as effective and valid as the original.

Consent for Vaccinations

Notice of Privacy Practices-HIPAA

Text Message Authorization