Pediatric Registration Form

Please bring all insurance cards as a copy will be made at the time of the appointment.

Assignment and Release

*I authorize payment of benefits directly to Drs. Gordon A. Price & Associates for services rendered. I also authorize release of any medical information that may be required in determination of such benefts.

*I understand that some services may require approval of my child's primary care physician for coverage and that, if I don't obtain that approval, I am financially liable for the services.

*I understand that my insurance carrier may not cover some services and products and benefit information does not constitute approval of payment. Deductibles & fees not paid by my insurance carrier will be my responsibility.

*I acknowledge that I received a copy of Drs. Gordon A. Price & Associates "NOTICE OF PRIVACY, HIPAA" policy.

Check Preference

Medical History Questionnaire

Ocular History:

(Select all that apply by holding Ctrl and clicking)

Medical History:

(Select all that apply by holding Ctrl and clicking)

(Select all that apply by holding Ctrl and clicking)

Family History

(Select all that apply by holding Ctrl and clicking)

Social History