CONSENT AND FINANCIAL POLICY
PATIENT’S NAME: ___________________________
DATE OF BIRTH: ___________________________
WELL CHILD EXAM/ROUTINE PHYSICAL – HEALTHY CHILD WITHOUT SYMPTOMS
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Includes:
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Immunizations
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Monitoring growth and development
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Give advice on healthy behavior
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Discuss preventive steps to promote good health
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Vision and hearing
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NOT included: subject to copay or deductible
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Abnormal findings
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New disease/condition/symptoms
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Management of chronic disease/conditions
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Medications for illness
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Medication refills
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Daycare/school clearance
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Sport/camp physicals
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Referrals to specialists/therapies
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In-office labs/procedures
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Follow-up visits
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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
_______________________________