CONSENT AND FINANCIAL POLICY

 

PATIENT’S NAME:  ___________________________ 

DATE OF BIRTH:     ___________________________

 

WELL CHILD EXAM/ROUTINE PHYSICAL – HEALTHY CHILD WITHOUT SYMPTOMS

  • Includes:

    • Immunizations

    • Monitoring growth and development

    • Give advice on healthy behavior

    • Discuss preventive steps to promote good health

    • Vision and hearing
       

  • NOT included: subject to copay or deductible

    • Abnormal findings

    • New disease/condition/symptoms

    • Management of chronic disease/conditions

    • Medications for illness

    • Medication refills

    • Daycare/school clearance

    • Sport/camp physicals

    • Referrals to specialists/therapies

    • In-office labs/procedures

    • Follow-up visits
       

I acknowledge that I may ask my provider to evaluate and manage my medical problem(s) during my preventive WELL EXAM and that the treatment will result in a separate office visit to be billed in addition to the preventive WELL EXAM.

Parent/Guardian Signature

_________________________________________                                                                               

 

Date          

______________________________

Parent/Guardian Printed Name

__________________________________________                                                                             

 

Relationship to Patient

_______________________________

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3645 Cypress Creek Pkwy, Suite 278
Phone: 832-688-8946
Fax: 832-688-8621

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