CONSENT AND FINANCIAL POLICY

 

PATIENT’S NAME:  ___________________________ 

DATE OF BIRTH:     ___________________________

 

WELL CHILD EXAM/ROUTINE PHYSICAL – HEALTHY CHILD WITHOUT SYMPTOMS

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• 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.

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Parent/Guardian Signature

_________________________________________                                                                               

 

Date          

______________________________

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Parent/Guardian Printed Name

__________________________________________                                                                             

 

Relationship to Patient

_______________________________

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