PATIENT REGISTRATION
PATIENT REGISTRATION
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Medical History Front
Medical History Front
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Medical History Back
Medical History Back
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Medical Records Release
Medical Records Release
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HIPAA & CONSENT
HIPAA & CONSENT
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ACKNOWLEDGEMENT FORM
ACKNOWLEDGEMENT FORM
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english  Patient Registration

 Spanish  patient registration 

PATIENT REGISTRATION
PATIENT REGISTRATION
press to zoom
Medical History Front
Medical History Front
press to zoom
Medical History Back
Medical History Back
press to zoom
Medical Record Release
Medical Record Release
press to zoom
HIPAA & CONSENT
HIPAA & CONSENT
press to zoom
ACKNOWLEDGEMENT FORM
ACKNOWLEDGEMENT FORM
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Miscellaneous

Release
Release
Survey
Survey
Complaints
Complaints
Photos
Photos
Labs
Labs
Consent
Consent
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© 2012-2021 by Fort Payne Pediatrics.

Please note that no one will be denied access to services due to inability to pay.
There is a discount/sliding fee schedule available. Please contact our office for more information.