Authorization for non-Parent (non-Guardian) to accompany Patient

Office Visit Form

This form is required (before your child is seen) If your child is:  “New Patient” (regardless of the reason for the visit), or “Established Patient” being seen for health check.  Please fill out and submit the form online before your child’s appointment date.  Please note that this form is specific to your child’s age, so make sure to select the age that reflects the exact age of your child to avoid submitting the wrong form. Office Visit Formatient’s Intake Form typically takes 20 minutes to finish.  Please fill out online before your office visit.  Having the form filled out ahead of time will speed up your check-in process on the day of your appointment.  We request that you arrive 1 hour early if you prefer to fill out the form in our office on the day of your visit. 

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Confirming an appointment

Please confirm your appointment one day before your appointment’s date to avoid cancellation.   You may confirm your appointment by Calling our office or Online.

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Cancelling an appointment

Please cancel your appointment one day in advance if (and for any reason) you are unable to keep your appointment. You may cancel appointment by Calling our office or Online.

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Financial Policy

  • Self-pay patients are expected to pay before they are seen by the physician.

  • Co-payments are the patient’s responsibility and will be due before seeing the Doctor.

  • We will submit claims (for service provided) to insurance companies directly. Any remaining balance is the patient’s responsibility and must be paid by the patient.

  • We accept cash, checks, MasterCard, American Express, Visa and Discover cards.

  • There will be a $25.00 fee for returned checks.