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On-Site  Vaccinations
Has your child seen their doctor for an annual check up this year? Are they up-to-date on their vaccinations?
It can be a problem for school, daycare, or summer camp if they haven't. 

 Our healthcare partner, C3 Cares, can get them up to date on needed vaccinations.



NOTE: ****Please submit a form for each child you'd like to register.
Sign in to Google to save your progress. Learn more
Which Event will your child attend? 
Child's First & Last Name

 *
Child's Date of Birth *
MM
/
DD
/
YYYY
Child's Health Insurance Plan *
Required
Child's Insurance Member ID *
Parent / Legal Guardian: First & Last Name *
Parent / Legal Guardian: Phone Number *
Parent / Legal Guardian: Email *
Does your child need routine immunizations? *
If your child has any allergies to drugs or food, special medications, health conditions, or any other pertinant information you'd like shared with the doctor, please elaborate here:
Questions / additional comments? 
CONSENT TO TREAT
I hereby consent and authorize Community Concierge Cares to furnish me or the above registered patient
with necessary medical care. This care may include ancillary care including but not limited to laboratory
testing, radiologic examinations and other diagnostic procedures as deemed necessary by the professional
staff at Community Concierge Cares. 

1. I understand that the services recommended to, or provided to me are in my, or the registered patient's best interest. I understand that I have and reserve the right to revoke this consent at any time and for any reason during my treatment at Community Concierge Cares. I consent to be contacted by mail, email, and telephone regarding matters related to my treatment or patient account
Community Concierge Cares and entities formally associated with Community Concierge Cares.

2. RELEASE OF MEDICAL RECORD INFORMATION. I hereby authorize the Practice to disclose all
or any part or the contents of the medical record of the patients named on this Registration Form to such
insurance companies, organizations, or agencies that may be concerned with the payment of medical
services rendered to the registered patient(s) consistent with Federal HIPAA regulations. This authorization
is given with full knowledge and understanding that such disclosure may contain information which may
result in a valid denial of insurance benefits, or which otherwise may not serve the interests of the registered
patient(s) or myself.

3. ASSIGNMENT OF INSURANCE BENEFITS: I hereby request and authorize that any and all
insurance benefits due and payable for medical services rendered to the patients(s) be paid directly to the
Practice. I am giving this consent freely and knowingly to provide for the child(ren) and not due to
pressure, threats, or payments by any person or agency.
Upon notification of intent to revoke, there shall be a period of 24 hours before revocation takes effect.
Notification of intent to revoke must be in writing.
I hereby swear or affirm that the above statements are true, under penalty of law.
Signature and date of parent or guardian
 *
*
Required
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