Gwinnett Pediatrics and Adolescent Medicine, Gwinnett Pediatricians logo for print
Gwinnett Pediatrics & Adolescent Medicine
Lawrenceville Office: 595 Hurricane Shoals Rd NE, Lawrenceville, GA 30046 | Phone: 404-355-0078
Duluth Office: 3855 Pleasant Hill Rd, Duluth, GA 30096 | Phone: 770-995-0823
Hamilton Mill Office: 2089 Teron Trace, Suite 100, Dacula, GA 30019 | Phone: 770-995-0823
Sugar Hill Office: 4700 Nelson Brogdon Blvd NE #180, Sugar Hill, GA 30518 | Phone: 770-995-0823

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Patient Information:
Patient Last Name: Name of Guarantor
(Responsible Party):
Patient First Name: Address:
Patient Middle Name: City/State:
Address: Relationship to Patient:
City, State: Date of Birth:
Zip: Social Security No.:
Home Phone: Phone:
Work Phone: Emergency Contact Information
Mobile Phone: Name:
Sex: Male Female Relationship:
Date of Birth: Phone:
Social Security No.: Mobile Phone:
Parent Email:
Required by government mandate (Although you may Refuse): Employer Information
Language: Employer:
Race: Address:
Ethnicity: Phone:
Marital Status:
Other: Pharmacy Information:
Patient Referred by: Name:
Crossroads:
Contact Preference: Phone:
Insurance Information
Insurance Plan Name: Address:
Last Name:
(Of the policy holder)
City:
First Name:
(Of the policy holder)
State:
Middle Name: Zip:
Date of Birth:
(Of the policy holder)
Sex: Male Female
Employer Name: Employer Address:

To the best of my knowledge, the above information is complete and accurate.

Signed: Date:

ACKNOWLEDGEMENT AND AUTHORIZATION: PLEASE READ ALL STATEMENTS BELOW AND SIGN

I have been given the opportunity to read the HIPAA/Privacy Policy for Gwinnett Pediatrics and Adolescent Medicine.

Signed: Date:

I hereby assign my insurance benefits to be paid directly to Gwinnett Pediatrics and Adolescent Medicine. I authorize Gwinnett Pediatrics and Adolescent Medicine to release medical information required to process my claims for services received. I authorize Gwinnett Pediatrics and Adolescent Medicine to pursue any unpaid or incorrectly adjudicated claims.

Signed: Date:

I have read and understand the Financial Policy for Gwinnett Pediatrics and Adolescent Medicine. I understand that I am responsible for all amounts not covered by my health insurance.

Signed: Date:

I authorize Gwinnett Pediatrics and Adolescent Medicine to obtain/have access to my medication and vaccine history.

Signed: Date:

I authorize Gwinnett Pediatrics and Adolescent Medicine to contact me with automated text alerts. (text alerts will notify you if lab results are available, provide appointment reminders, and other important office messages.)

Signed: Date:

I authorize Gwinnett Pediatrics and Adolescent Medicine to leave messages regarding my child's health on my voicemail.

Signed: Date:

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