Patient Information


    MaleFemale

    Primary Guardian Information


    MaleFemale

    MarriedSingleDivorcedWidowedSeparated

    Secondary Guardian Information


    MaleFemale

    MarriedSingleDivorcedWidowedSeparated

    Primary Insurance

    Secondary Insurance

    Other Children

    Emergence Contact Information

    Please list anyone other than the primary & secondary guardian that can bring this child into our office for treatment

    Notice of Privacy Practice.

    Financial Obligation

    Please initial by each statement and sign and date at the bottom

    I understand that I am ultimately responsible for all charges incurred on behalf of my minor child or the child who is seeking medical care while in my custody. Any co-pays, deductibles, or charges which are denied coverage from my commercial insurance company are my responsibility and will be paid at the time they are incurred.
    I hereby authorize the release of any medical information necessary to process insurance claims or any medical information that is required for any health care related utilization review or quality assurance activities.
    I hereby assign and authorize payment to Lifeguard Pediatrics, PC of all medical/surgical/major medical benefits to which I am entitled under any insurance policy or policies, under any self-insurance program or under any other benefit plan.
    I understand and acknowledge that this assignment of benefits does not relieve me of my financial responsibility, including, but not limited to, payment of those fees and charges not directly reimbursed to Lifeguard Pediatrics by any insurance policy, self-insurance plan, or other benefit plan.
    This authorization shall remain in effect until revoked by me in writing. A photocopy of this authorization shall be considered as effective and valid as the original. I understand that I have the right to receive a copy of this authorization.

    Opening Hours

    Opening Hours

    Mon-Thu: 8:00 am – 5:00 pm
    Friday: 8:00 am – 3:00 pm
    Saturday: 9:00 am – Noon
    Closed on Sunday
    Public Holidays: as advertised