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

Office Visit Form

Office Visit 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 checkPlease note that this form typically takes 20 minutes to finish and 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. Please fill out and submit the form online before your child’s appointment date by latest 12 noon one day prior to your child’s scheduled visit.   


Confirming an appointment

Please confirm your scheduled appointment by latest 12 noon one day before your appointment’s date, all unconfirmed appointment will be rescheduled. You may confirm your appointment by Calling our office or Online.


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.


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.