The Professional Association for Pediatrics



Please fill out the section pertaining to you.

Employer Information:


We must have a copy of your current insurance card at each visit.

Subscriber's Information:


Nearest Relative NOT living with you


Medication Allergies



Upon the completion of each visit, you are requested to stop at the Bookkeeping Desk for an itemized statement of services rendered. This is the times to be certain that all charges are clearly explained and that they are fully understood. You are given a time of service receipt or insurance receipt upon request. Payment is due at the time of your visit unless previous arrangements have been made.


I authorize below the following:
1. Release of any medical information necessary to process this claim. I permit a copy of this authorization to be used in the place of the original.
2. I hereby authorize The Professional Association of Pediatrics to apply for benefits on my behalf for covered services rendered by the association, or by their order. I request that payment from my insurance company be made directly to The Professional Association for Pediatrics.
3. I have been given this office's Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of the document.
4. I certify that my insurance and address listed or corrected above is correct.
5. AUTHORIZATION FOR CARE: I hereby consent to and authorize The Professional Association for Pediatrics and its affiliates, its employees and contractors, to provide services and administer physician orders. This may include: routine care, immunizations and emergency care as deemed necessary by the physician.
6. PORTAL and ONLINE SUBMISSION: I acknowledge that I have read and fully understand this consent form. I have been given risks and benefits of patient portal and submitting personal information online. I agree that I understand the risks associated with online communications between my physician and patient, and consent to the conditions outlined herein. I agree not to hold The Professional Association for Pediatrics or any of its staff or physicians liable for network or security infractions beyond their control. Portal and online form submission is entirely voluntary and will not impact the quality of care I receive from The Professional Association for Pediatrics should I decide against using these services. In addition, I agree to adhere to the policies set forth herein, as well as any other instructions or guidelines that my physician may impose for online communications. I have been proactive about asking questions related to this consent agreement. All of my questions have been answered with clarity. I understand that this agreement is good for life unless I submit written request to be removed.

Professional Association for Pediatrics Vaccine Policy Statement

As pediatric health care providers our highest priority is to protect the health and well-being of your children and our community. We believe that routine childhood immunizations are crucial in meeting this goal. Vaccines are one of the most helpful interventions in the history of modern medicine.

  • We firmly believe in the effectiveness and safety of vaccines to prevent serious illness and to save lives. If we did not, we would not recommend them for our own children or yours.
  • We firmly believe that all children and young adults should receive all of the recommended vaccines according to the schedule published by the Center for Disease Control (CDC) and the American Academy of Pediatrics.
  • We firmly believe, based on all available literature, evidence and current studies, that vaccines do not cause autism or other developmental disabilities.
  • We firmly believe that vaccinating children and young adults may be the single most important health promoting intervention we utilize as health care providers, and that you can use as parents. The recommended vaccines and their schedule given are the results of years of scientific study and data gathering on millions of children by thousands of the world's brightest scientists and physicians.
  • We recognize that there has been controversy surrounding vaccination. Because of vaccines, many of you have never seen a child with polio, tetanus, whooping cough, bacterial meningitis or even chicken pox, or known a friend or family member whose child died of one of these diseases. Such success can make us complacent or even question the need for vaccinating our children. But such an attitude may lead to tragic results.
  • We therefore emphasize the importance of vaccinating your child. We recognize that the choice may be a very emotional one for you. We will do everything we can to show you that vaccinating is the right thing to do. However, should you have doubts, please discuss these with your health care provider.
  • Finally, if you should choose not to vaccinate your child or not to vaccinate on schedule, we will ask you to find another health care provider who shares your views. Please recognize that by not vaccinating, you are putting your child at unnecessary risk for life-threatening illness, disability and even death.

© 2018 Pediatrics Associates – CREATED BY GOOD THINGS