Under 18 New Patient Registration Packet

GLENDALE PEDIATRICS

Consent for Treatment
I hereby authorize the physicians of Glendale Pediatrics and their designees to provide medical treatment as deemed necessary to my minor child(ren):
Consent is hereby granted by:*

Clear
Name

First NameLast Name
Relationship to Patient
Date

MonthDayYear
Date
This authorization shall remain in effect until revoked in writing.

CONSENT FOR TREATMENT - REV. 11/2023

CREDIT CARD AUTHORIZATION
I Initials authorize Glendale Pediatrics to charge my unpaid co-payment, work-in charges, and 60-day balance due to the credit card listed below. This authorization will automatically renew at the expiration date of the credit card and remain in force on each of my children's accounts until they are no longer patients of Glendale Pediatrics:
Print Cardholder's Name

First NameLast Name
Cardholder's email
example@example.com
VISAMCDISAm Ex
Last 4 Digits of Card Number
Cardholder's Signature

Clear
Date

MonthDayYear
Date
PLEASE PROVIDE CREDIT CARD TO OUR FRONT DESK TO BE SCANNED & PLACED ON FILE.

OFFICE PROCEDURE, FINANCIAL POLICIES/PAYMENT FOR SERVICES ACKNOWLEDGEMENT PAGE

Birth through 17
CANCELLATION POLICY

A specific time is reserved for you when you schedule an appointment. If you cannot keep your scheduled appointment, please give us at least 24 hours notice so that we may reschedule the appointment and offer the reserved time to another patient. It is our policy to charge $75 for appointments that have been scheduled in advance and are canceled/missed with less than 24 hours notice. Please be aware that this applies to same-day appointments as well; however, if your appointment is booked and canceled within one hour, there will not be a cancellation fee.
UNSCHEDULED APPOINTMENTS

Appointments requested in the office without prior arrangement will be made according to our discretion with consideration given to other patients' scheduled appointments. Any unscheduled patient who requests that one of our physicians work them into their schedule will be charged a work-in fee of $50. This fee is not covered by insurance and is due at the time of service.
ADDITIONAL HEALTH ISSUES ADDRESSED DURING PREVENTIVE CARE APPOINTMENTS.

Preventive Care is an important part of healthcare. If, during an annual physical well visit, your child is sick or has an issue that is not related to the routine health maintenance and development of your child that needs treatment and/or medical attention/guidance for your concerns, your provider may bill the insurance company for both services. Your insurance benefits may require that you pay a co-pay, co-insurance and/or may apply the visit to your deductible. Please note that medical questions regarding an unscheduled sibling will be billed as an office visit.
SATURDAY APPOINTMENTS

We offer Saturday morning appointments for urgent visits. While we are happy to offer this appointment-only service, please be aware that there is an additional $60 fee for weekend appointments.
CREDIT CARD POLICY

At check-in, your credit card information will be obtained and stored securely. In the event that your authorized card changes or is declined, you agree to immediately notify Glendale Pediatrics and provide us with a new, valid credit card which will be used to charge any payments as described above.

A $35 fee will be charged if your credit card payment is declined for any reason. Please make sure that the card information you give us is accurate and that your credit card on file remains valid at all times.

Cash patients will need to pay in full at the time of service. For your convenience, we accept cash, checks, MasterCard, Visa, American Express and Discovery Card. There is a $35 charge for all returned checks.
Parent or Guardian Printed Name

First NameLast Name
Parent or Guardian Signature

Clear
Date

MonthDayYear
Date
2025 Financial Policy Acknowledgment form 12/2024

PATIENT INFORMATION COMMUNICATION FORM
Family Members / Caregivers Involved in Patient Care:

Disclose information about my child's care or treatment to only the following family members or friends (initial all that apply):
Initial Parent/Legal Guardian 1 (Name) First Name Last Name
Initial Parent/Legal Guardian 2 (Name) First Name Last Name
Initial Stepparent 1 (Name) First Name Last Name
InitialStepparent 2 (Name) First Name Last Name
InitialOther Relationship First Name Last Name
InitialDo not disclose information about my child's care or treatment to any individuals, regardless of the relationship.
Patient / Responsible Party Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Relationship to Patient

CONSENT TO PARTICIPATE IN TELEMEDICINE CONSULTATION
PURPOSE

The purpose of this form is to obtain your consent for a telemedicine consultation with a physician. The purpose of this consultation is to assist in the diagnosis or treatment of the patient.

NATURE OF TELEMEDICINE CONSULTATION

Telemedicine involves the use of audio, video or other electronic communications to interact with you/ your child, consult with your healthcare provider and/or review your medical information for the purpose of diagnosis, therapy, follow-up and/or education. During your telemedicine consultation, details of your medical history and personal information may be discussed with other health care professionals through the use of interactive video, audio and telecommunications technology. Additionally, a limited physical examination of the patient may take place, and video, audio and/or photo recordings may be taken.

RISKS, BENEFITS AND ALTERNATIVES

The benefits of telemedicine include, but may not be limited to, having access to health care and additional medical information and education without having to travel outside of your home. A potential risk of telemedicine is that because of the patient's specific medical condition, or due to technical problems, a face-to-face consultation may still be necessary after the telemedicine appointment. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to telemedicine consultation is a face-to-face visit with a physician.

MEDICAL INFORMATION AND RECORDS

All laws concerning patient access to medical records and copies of medical records apply to telemedicine. Dissemination of any patient identifiable images or information from the telemedicine consultation to researchers or other entities shall not occur without your consent.

CONFEDENTIALITY

All existing confidentially protections under federal and California law apply to information used or disclosed during your telemedicine consultation.

RIGHTS

You may withhold or withdraw your consent to a telemedicine consultation at any time before and/or during the consult without affecting your right to future care or treatment, or risking the loss or withdrawal of any benefits to which you would otherwise be entitled.
I have read and understand the information provided above. I understand that I am encouraged to ask questions of my physician about this information, should I have any. I have read and hereby agree to telemedicine consultation.

Clear
Print name of Parent/Guardian

First NameLast Name
Date

MonthDayYear
Date

Glendale Pediatrics

A Professional Corporation
Except for life threatening emergencies, we are not able to treat your minor child unless he or she is accompanied to our office by a parent, legal guardian or a designated adult.

In order to designate an adult to bring your child into our office for medical care in your absence, you must have the following form(s) completed, signed and on file for each designated adult for each of your children.

Minor children reporting for an appointment without a parent, legal guardian, an adult named in a signed designee form or a signed note from a parent may need to be rescheduled.
Alternate Caregiver Consent Form

I authorize the following individual(s) to bring in my child / children to their appointments:
Alternate Caregiver's Name

First NameLast Name
Relationship to my child
Alternate Caregiver's Name

First NameLast Name
Relationship to my child
Alternate Caregiver's Name

First NameLast Name
Relationship to my child
I attest that the above named individual(s) is/are 18 years of age or older as of this date. I authorize the above named individual(s) to consent to treatment for my child(ren). This may include, but, is not limited to, consent for necessary medications, vaccinations, procedures and hospitalization. Glendale Pediatrics may relay any medical information about my child necessary for the above named individual(s) to provide informed consent to the treatment.

I understand that the doctor will communicate his or her findings and treatment plan to the caregiver who brings in the child, and that under most circumstances, a follow-up call to me personally should not be necessary.

I agree to hold Glendale Pediatrics and its staff harmless for any disagreement between the above named individual(s) and myself regarding treatment decisions.

I attest that I am the parent or legal guardian of the following children and that I have the legal authority to make this agreement. I understand that I can revoke this authorization for any or all of these individuals at any time.
Signature

Clear
Parent or Guardian's Name

First NameLast Name
Date

MonthDayYear
Date

2024 Annual Administrative Fee Acknowledgement

Starting August 1, 2024, Glendale Pediatrics has instituted an annual Administrative Fee. The Administrative Fee is intended to cover services not covered by health insurance. I have read and understand the Annual Administrative fee policy. By signing below, I agree to assume financial responsibility for the payment of the Administrative Fee.
Patient's Parent Legal Guardian Name

First NameLast Name
Patient's Parent Legal Guardian Signature

Clear
Relationship to Patient
Date

MonthDayYear
Date
Email
example@example.com
Family Size

____________________________________________________________________________________________________
$90 (1 Child)$150 (2 Children)$180 (3 or more Children)
Month Paid
Initials Initials I authorize Glendale Pediatrics to charge my annual Administration Fee each year on the credit card noted below. The authorization will automatically renew at the credit card's expiration date and remain in force on each of my children's accounts until they are no longer patients of Glendale Pediatrics. Patients will be notified 30 days in advance in the event that forthcoming annual administrative fee is modified.
Initials
Print Cardholder's Name

First NameLast Name
Cardholder's Email
example@example.com
VISAMCDISAM EX
Last 4 Card Numbers
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

PLEASE LIST CHILDREN'S FULL LEGAL NAME:

Address:

1. Parent or Legal Guardian Information

IN CASE OF EMERGENCY, CONTACT:

GLENDALE PEDIATRICS

CREDIT CARD AUTHORIZATION

OFFICE PROCEDURE, FINANCIAL POLICIES/PAYMENT FOR SERVICES ACKNOWLEDGEMENT PAGE

PATIENT INFORMATION COMMUNICATION FORM

Family Members / Caregivers Involved in Patient Care:

CONSENT TO PARTICIPATE IN TELEMEDICINE CONSULTATION

Glendale Pediatrics

Alternate Caregiver Consent Form

Family Size