SoFHA
Patient Forms

Yearly Paperwork


Description:

The Riverside Pediatrics yearly patient paperwork.


Code:

2.101

Issued:

08/06/2018

Revision:

2

Revised:

N/A

Patient Information




















Mother's Information














Father's Information














Acknowledgement of Notice of Privacy Practices

I have been given the opportunity to review the Notice of Privacy Practices and understand that the Notice describes how my protected medical information may be used and disclosed and how I may get access to this information. I have also been given the opportunity to take a copy of the Notice of Privacy Practices for further review.

If for some reason the facility needs to relay my protected medical information, i.e. lab results or billing issues, you can either leave a message with or discuss the information with the following individual(s):



















Emergency contact number other than YOUR main phone number:




Consent to Treatment of a Child by Authorized Person

The undersigned parent or legal guardian of the child specified above authorizes the person(s) listed below to consent to treatment of the child, including, but not limited to, emergency, x-ray, anesthetic, or surgical services when I am not immediately available in person, or by a telephone call to my main number.

It is understood that this consent is given in advance of any specific diagnosis or treatment and allow the physician/provider to diagnose and treat the child even when the parent or guardian is not present.

Person(s), besides parents, who may consent to treatment:





















Appointment Agenda


Health Leads Screening













Signer Information










By typing your name in the signature field below, you consent to all of the agreements listed in this form. You furthermore agree that your submission of this form, via the "Submit Form" button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.