New Patient Form Part 1 of 2: Legal Guardian/Insurance Info, Financial Policies, Appointment Policies, & HIPAA Consent (one per family please)
Please note, this form must be completed by a legal guardian. Please complete this form only once for your entire family.
Email address *
Please list the full name of the person completing this form. *
Please list the names and dates of birth for the children this form applies to. *
Please confirm the person completing this form is the legal guardian of the above listed children. *
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