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Patient and Family Information

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Relationship:*
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Relationship:
 
 
 

Child's Health History (New patients only, not newborns)

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Does your child take vitamins, flouride, iron, or other supplements?:*

Please check all that apply to your child:

 













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Other

Assignment and Release

I hereby authorize payment direct to Lakeview Pediatrics, LLC for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance,a nd for all services rendered on my behalf or my dependents.

I authorize the above doctor and/or any provider or supplier of services in this office to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Parent

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