This form is required to be completed before or at your first visit with a patient under 18 and must be filled out by a parent or legal guardian. Parent or legal guardian may also need to be present during the first visit. Please check with your doctor or therapist before coming to your appointment. To make your first visit run as smoothly and as efficiently as possible, we request that you download, print, and fill out this form in advance and bring it to your first appointment.
If you have not yet read our First Visit page, please do so before you fill out this form. If you were instructed to fill out Patient Registration or Adult Forms, please click the links and do so as well.
TO DIVORCED PARENTS OF MINOR CHILDREN
In order for us to evaluate and treat minor children, it will be necessary for you to bring a copy of the custody order with you at the time of your first visit. In addition, the parent who accompanies the child to their appointments will be responsible for paying any copays or deductibles due at the time of the visit.