Established Patients Under 18 Packet

PATIENT INFORMATION COMMUNICATION FORM
Patient's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Patient's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
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
Initial Stepparent 2 (Name) First Name Last Name
Initials Other Relationship First Name Last Name
Initial Do 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:

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, Amerivan Express, and Discovery Card. There is a $35 charge for all returned checks.
Parent or Guardian Name*

First NameLast Name
Parent or Guardian Signature*

Clear
Date*

MonthDayYear
Date
2025 Financial Policy Acknowledgment form 12/2024
Should be Empty:

PATIENT INFORMATION COMMUNICATION FORM

Family Members / Caregivers Involved in Patient Care

OFFICE PROCEDURE, FINANCIAL POLICIES/PAYMENT FOR SERVICES ACKNOWLEDGEMENT PAGE