hereby authorize and consent to the examination/treatment of my child(ren) during the office and facility visits by the physician and clinical staff of Poole and Thomas Pediatrics. In addition, I give permission for the following person(s) to bring my child to Poole and Thomas Pediatrics in my absence and to act on my behalf in authorizing medical care and treatment in my absence. In the event of an emergency or other illness, I understand that the providers and staff of Poole and Thomas Pediatrics will deliver any medical care deemed necessary regardless of the accompanying adult.

Anyone not mentioned above who brings your child into the office for treatment must have a signed authorization from the child(ren)'s legal guardian. Until we are notified in writing, Poole and Thomas Pediatrics will assume that a child's biological and/or legal parents are both legal guardians who have access to treatment options and medical information for that child.

Co-pays, co-insurance, and deductibles are due at the time of service. Private pay patients are expected to pay in full at the time of service also. If there is an outstanding balance on your account, the balance can be paid in full online, via the patient portal, or during your visit to our office.

Accounts not kept up to date will be turned over to collections per our financial policy. A full copy of this policy can be obtained on our website www.ptpediatrics.com or upon request to our office staff.

At Poole and Thomas Pediatrics, we are committed to protecting the security and privacy of your child’s personal information. Medical records are the property of Poole and Thomas Pediatrics. These records are kept in a secure location and are accessed only for the purposes outlined by the Notice of Privacy Practices (Revised 4/1/19). Our revised Privacy Notice is available at www.ptpediatrics.com, or you may request a copy from our office. Records may be released or shared with your health insurance plan as well as other healthcare professionals for the treatment of your child. Patients are entitled to one free copy of their medical records only after an authorization for release is signed.

By signing below, I acknowledge that I have received Poole and Thomas Pediatrics Notice of Privacy Practices and
consent to treat information. I understand that I can edit any of the terms below.

• I understand that PTP may call my home and place of employment for healthcare reasons, appointment reminders, and to resolve billing issues. They may also send informational postcards and bills to my home mailing address.
• I understand that PTP may leave messages on my answering machine or voice mail regarding appointments and limited
  test information.
• I understand that PTP may use an email address or fax that has been provided by me to communicate appointment
  information, billing issues, immunization certificates, test results, and other forms requested by the parent/guardian.
• I authorize PTP to email or fax immunization certificates and/or school forms, or to mail to my home address provided.
• I authorize PTP to discuss patient information with adults or other minors present during the visit regardless of whether I am present.
•  I understand that if I send a picture of myself or child(ren) PTP may display it within the office.