Please fill out the New Patient Form below; required fields are marked with an asterisk (). Social security and driver's license number will be entered on the printed version of this form.
Please enter SSN# on the printed form
The information below is optional, but will help us process your information faster when you arrive.
In the event of an emergency, whom should we contact? (Someone other than the parent or guardian)
Because your child is a minor, it becomes necessary that a signed permission be obtained from a parent/guardian before any and/or all necessary medical services can be started and accomplished by the physicians at University Pediatric Association.
I authorize the release of any medical or other information required in the processing of claims. I authorize my insurance benefits to be paid directly to the health care provider.
My signature as parent/guardian affixed below authorizes the rendering of medical services. This consent shall remain in full force and effect until cancelled by either party. I understand that I am financially responsible for all charges incurred as a result of medical services rendered.
In my absence, the following persons may present my child for medical treatment:
