• New Patient Registration

  • Patient Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Parent or Guardian 1

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Relationship Status*

  • Parent or Guardian 2

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Relationship Status*

  • Emergency Contact

    We will always contact parents first. If we are unable to contact parents, we will contact emergency name provided.
  • Format: (000) 000-0000.
  • Does your child have medical insurance?*

  • Primary Insurance

  • Insurance is through:*
  • Date of Birth of Policy Holder*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Effective Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Does your child have secondary medical insurance?*

  • Secondary Insurance

  • Insurance is through:*
  • Date of Birth of Policy Holder*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Effective Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Financial Policy: Self-Pay

  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Patient Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Thank you for the confidence you have placed with us by allowing us to participate in your healthcare. The following is a statement of our financial self-pay policy, which we require you to read and sign prior to treatment.

    Your account is SELF-PAY at this time.

    If you do have insurance, you must provide proof of the insurance card within 30 days of the date of service. All insurance claims must be filed in a timely manner. If we receive your insurance information after the timely filing deadline, the balance due will be your responsibility.

    I have read and understand the above policies and accept my responsibilities as stated above. I agree to pay any and all charges.

    We accept Cash, Checks, Visa, Mastercard, Discover, or American Express.

  • Authorization for Insurance Reimbursement

  • I hereby authorize the release of such information as may be necessary to implement the coordination of benefits to Waggoner Pediatrics of Central Iowa.

  • I hereby authorize payment of medical benefits directly to Waggoner Pediatrics of Central Iowa.

  • Health Insurance Portability and Accountability Act of 1996 (HIPAA)

    I authorize the disclosure of patient individual health information when necessary, including but not limited to when required by law, when working with laboratories and testing facilities, and for billing purposes. For complete HIPAA disclosure conditions and use information, please ask the billing office.
  • Should be Empty: