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Patient Name
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DOB
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Please provide information on any family members or friends you want us to be able to speak with concerning your child. You may opt out by checking Do Not Release Information to Anyone. The patient’s representative will choose a password or phrase which must be relayed to the office staff before Kids First Pediatrics will disclose any information concerning your child over the phone.
Chosen Password
*
Contact Method
*
Home Phone
Cell Phone
Work Phone
Send Email
Regular Mail
Text Message
DO NOT RELEASE INFORMATION TO ANYONE IN ANY MANNER
Contact Number
Ok to leave Voicemail
Yes
No
OK to leave a message with another person
Yes
No
Contact Number
Ok to leave Voicemail
Yes
No
OK to leave a message with another person
Yes
No
Contact Number
Ok to leave Voicemail
Yes
No
OK to leave a message with another person
Yes
No
Email Address
Email appointment reminders
Email medical information or additional scheduling information
Email office announcements
Mailing Address
If OK, please list cell carrier (e.g., Verizon, AT&T):
Text appointment reminders
Text medical information or additional scheduling information
Text office announcements
I give the following individuals authorization to take messages or speak with Kids First Pediatrics of Georgia on my child’s behalf: (please check all items authorized)
Name of authorized person
Relationship
Phone Number
Appointments
Financial
Medical Treatment
Insurance
Other
Name of authorized person
Relationship
Phone Number
Appointments
Financial
Medical Treatment
Insurance
Other
Name of authorized person
Relationship
Phone Number
Appointments
Financial
Medical Treatment
Insurance
Other
Please mark the ways that you consent to us communicating with you:
I understand that with my signature below, I acknowledge and understand that this information will be kept in my medical record and the above parameters will remain in effect until revoked by me in writing. It is my responsibility to notify Kids First Pediatrics of GA should I wish to change one or more contacts listed above.
Signature of Patient’s Representative (or patient if over 18 yrs of age)
*
clear
Relationship to Patient
*
Printed name of Patient’s Representative
*
Date signed
*
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Please Note:
Any information submitted using this form is transmitted securely and held in the strictest of confidence, protecting your privacy.
* = Input is required