Common Contracts
1 similar Patient Information Form contracts
Patient’s Name ________________________________________________________________ _________________________ Last First Middle Address ___________________________ _______________________________________________________________________ Street & Apt # City...Patient Information Form • April 26th, 2022
The adult accompanying a minor and the parents (or guardian) of the minor are responsible for full payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized with a credit card, check, or cash payment at the time of service. As guardian of the minor I authorize treatment unless otherwise noted in writing.
