New Patient Forms

New Patient Forms

The CMS (Centers for Medicare & Medicaid Services) and the American Academy of Pediatrics have respectively required and recommended all the patient forms. All insurance companies are requiring us to have these completed for reimbursement. We apologize for any inconvenience this causes.

New Patient(s) Consent to Treat (Select Appropriate Clinic)

For which clinic is this form?
(MM/DD/YYYY)
I (we), the legal quardians of the above named children do hereby give my(our) consent for the persons listed below to obtain medical care for my (our) children at Storybook Pediatrics. I (we) understand that by giving persons permission to take my child/children to Storybook Pediatrics for medical care, I am also giving Storybook Pediatrics permission to disclose my child's (children's) protected health information to any of the persons on this list. I also understand that by giving these persons permision to take my child (children) to Storybook Pediatrics for medical care that I am also giving these persons my permission to make medical care decisions for my child (children) during those visits. Parent or Legal Guardian Signature: *

Guarantee of Payment

Storybook Pediatrics requires a credit, debit, or health savings card on file. Providing quality healthcare to our patients and good service to their parents is very costly. Adequate cash flow is critical to the financial viability of this practice; therefore, parents must provide a concrete guarantee of payment for services. I agree to place a credit, debit, or Health Savings Account card on file in my guarantor record. I understand that only the last four numbers of the card are visible to any employees who might have access to my guarantor record. I understand that after the processing of insurance claims is complete that I will be billed via email for any remaining amounts that are deemed patient responsibility and that the balance is due within 14 days of billing. Should payment not be received by this office within the 14 days subsequent to billing, I understand that the credit/debit card placed on file will be run to pay the balance. I understand that should the amount of the balance be problematic to pay within the 14 day window that it will be my responsibility to call the billing office and arrange a payment plan. I understand that MY CARD WILL NEVER BE CHARGED UNLESS I FAIL TO PAY MY ACCOUNT BALANCE WITHIN THE TIME LIMIT STATED ABOVE. *

Attendance Policy

In order to be fair to all of our patients, patients must arrive on time for their appointments in order to be seen by a nurse or provider. If a patient arrives late and there is room in the schedule, we will accommodate the patient by moving him/her into a later schedule slot. If there is no room in the schedule, you will be asked to reschedule. All appointments must be cancelled 24 hours in advance in order to avoid a $35 missed appointment fee. Appointments may be cancelled by calling our office during regular hours or emailing care@ronsmithmd.com outside of our regular office hours. *

Interim History Update

(MM/DD/YYYY)

Current Contact Information

Mom's Relationship
Email verification
Email verification
Father's Relationship
Email verification
Email verification
Email verification

Interim Medical History

Current Prescription Oral Medications

Current Prescription Topical Medications (creams, etc.)

Current Prescription Inhaled Medications

Current Over-the-Counter Medications

Allergies

Environmental

Primary water source (for children under six)
Does this child (if under age three) live in or frequently visit a house constructed before 1978?

Section

High blood pressure
High Cholesterol or Triglycerides
Heart Attack
Stroke
Type II Diabetes
Hypothyroid (low thyroid)
Lupus
Rheumatoid arthritis
Celiac Disease
Crohn’s Disease
Ulcerative Colitis
Type I Diabetes
Other Autoimmune Disorders
Free Bleeder
Clotting Disorder
Irritable Bowel Syndrome
Autism
Developmental Delay
Speech Disorder
Intellectual Disability
Learning Disability
ADHD/ADD
Anxiety Disorder
Depression
Mental Illness
Food allergies
Asthma
Hypertrophic cardiomyopathy
Wolf Parkinson White Syndrome
Prolonged QT Syndrome
Deafness
Vision Problems
Seizure disorder