Financial and Office Policy Forms
Each section will be a different form. By clicking "Yes" you state that you understand the office and financial policies of Advanced Pediatrics Gastroenterology and are in agreement with those policies.

An electronic copy of the financial and office policy forms will be sent to the front office of Advanced Pediatrics Gastroenterology. Clicking "Yes" to the following sections will be considered an "electronic signature" and your name will appear on each of the forms of the generated copy on submission.
Guarantor Name *
Parent of the child
Patient Name *
Patient Date of Birth *
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