CHILDRENS CLINIC

							                                   CHILDRENS CLINIC
                                    M.H.COLE, JR, MD
                                     NEWNAN, GEORGIA


PATIENT NAME_______________________________________________DATE OF BIRTH_________________
ADDRESS______________________________________________________________________________________
CITY_____________________________________ZIP CODE____________________________________________
SS#____________________________________MALE__________________FEMALE_______________

FATHER:                                       MOTHER:
NAME_____________________________________     NAME__________________________________________
ADDRESS_________________________________      ADDRESS_______________________________________
CITY_____________________ZIP_____________     CITY_____________________ZIP__________________
DATE OF BIRTH___________________________      DATE OF BIRTH_______________________________
SS#_______________________________________    SS#____________________________________________
HOME PHONE____________________________        HOME PHONE_________________________________
EMPLOYER______________________________        EMPLOYER___________________________________
WORK #___________________________              WORK #__________________________
CELL#____________________________              CELL#___________________________

INSURANCE INFORMATION: PLEASE PRESENT YOUR INSURANCE CARD TO THE RECEPTIONIST.
NAME OF PRIMARY INSURANCE COMPANY____________________________________________________
POLICY HOLDER’S NAME___________________________________SS#________________________________
NAME OF SECONDARY INSURANCE COMPANY__________________________________________________
POLICY HOLDER’S NAME___________________________________SS#________________________________

EMERGENCY CONTACT________________________________________________________________________
(IF UNABLE TO REACH PARENTS)
PHONE___________________________________________RELATIONSHIP______________________________

FINANCIAL RESPONSIBILITY:
NAME_________________________________________________________________________________________
ADDRESS______________________________________________________________________________________
PHONE_____________________________
EMPLOYER______________________________________WORK #_____________________________________

I CONSENT TO TREATMENT NECESSARY FOR THE CARE OF THE ABOVE NAMED PATIENT BY CHILDRENS CLINIC.
I AUTHORIZE THE RELEASE OF ALL MEDICAL RECORDS TO THE REFERRING PHYSICIANS AND TO MY INSURANCE
COMPANY, IF APPLICABLE.
I ALLOW FAX TRANSMITTAL OF MY MEDICAL RECORDS, IF NECESSARY.
I ACKNOWLEDGE FULL FINANCIAL RESPONSIBILITY FOR SERVICES RENDERED BY CHILDRENS CLINIC.
I UNDERSTAND THAT PAYMENT IS DUE AT TIME OF SERVICES UNLESS OTHER DEFINITE FINANCIAL
ARRANGEMENTS HAVE BEEN MADE PRIOR TO TREATMENT.
I AGREE TO PAY ALL OUTSTANDING BALANCES PRIOR TO LEAVING THIS PRACTICE.
I AGREE TO PAY ALL REASONABLE FEES AND A 40% COLLECTION FEE IN THE EVENT OF DEFAULT OF PAYMENT
OF MY CHARGES.
I FURTHER AUTHORIZE AND REQUEST THAT INSURANCE PAYMENTS BE MADE DIRECTILY TO CHILDRENS CLINIC.
I AUTHORIZE CHILDRENS CLINIC TO RENDER NECESSARY MEDICAL TREATMENT IN MY ABSENCE.
I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT FOR TREATMENT, FINANCIAL RESPONSIBILITY,
RELEASE OF MEDICAL INFORMATION, AND INSURANCE AUTHORIZATION.

SIGNATURE OF PARENT/GUARDIAN________________________________________DATE_____________________