Patient Information and Consent

Acknowledgement
You are hereby notified pursuant to Michigan Law that as a patient of this practice your child may be tested for the presence of HIV or an HIV antibody without your consent if any health professional or other health facility employee sustains a percutaneous membrane open wound exposure to your child's blood or other body fluids. This test is permitted by Michigan Law and is for the protection of your child as well as the protection of the physicians and employees of Muskegon Pediatrics.
Patient's Name*

First NameLast Name
Patient's Birthdate

MonthDayYear
Parent/Guardian

First NameLast Name
Parent/Guardian Signature*

Powered by Jotform SignClear

Consent for Care in Absence of Parent
I, the parent/guardian named below, give permission for these Authorized Persons to bring my child/children, the patients named below, to Muskegon Pediatrics when I am unable to attend.
Patient's Name*

First NameLast Name
Patient's Birthdate

MonthDayYear
Authorized Persons
Parent/Guardian

First NameLast Name
Parent/Guardian Signature*

Powered by Jotform SignClear

Authorization to Share Information with Caregivers

Complete this form to give Muskegon Pediatrics permission to share information about your children with authorized caregivers.
I, the parent/guardian named below, authorize the release and/or sharing of information about the Patient named below, with the following persons or entities listed below ("Authorized Caregivers").
Patient's Name*

First NameLast Name
Patient's Birthdate*

MonthDayYear
Authorized Caregivers
Parent/Guardian

First NameLast Name
Parent/Guardian Signature*

Powered by Jotform SignClear

Carequality Consent
Muskegon Pediatrics participates with the national Carequality registry. This registry allows hospitals and physicians across the country to exchange information regarding your health, such as current medications, most recent weight, height, blood pressure, and allergies. This exchange of information allows your child to receive better and informed care if he/she would need to visit an emergency room or see another physician.

If you would NOT like to have this information available, please provide this in writing to Muskegon Pediatrics.

I acknowledge that I was given this information.
Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature*

Powered by Jotform SignClear

HIPPA Acknowledgement
The Health Insurance Portability and Accountability Act (HIPAA) requires us to give you a notice of our privacy practices and to acknowledge your receipt of the notice.The Notice of Privacy Practices explains how your health information may be used and or disclosed by us. In addition, it explains your rights with regard to your protected health information, as well as our legal responsibilities. You can view the Privacy Practices in one of three manners: we can email you a copy, you can view it on our website, or you may request a paper copy.
I have been offered a copy of the Notice of Privacy Practices in electronic or paper format. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

YesNoOffered but declined
Child's Name

First NameLast Name
Child's Date of Birth

MonthDayYear
Date
Name of Person Signing

First NameLast Name
Signature

Powered by Jotform SignClear

Muskegon Pediatrics No-Show Policy
Muskegon Pediatrics understands that unexpected things happen which could prevent patients from keeping their appointment with us. With that in mind, we expect parent/guardian/patient to notify our office as soon as they know they cannot keep a scheduled appointment. In the event that they fail to notify us within 2 hours of their appointment (except in circumstances out of your control) they will be assessed a “no-show” appointment. Three “no-shows” per family per 12-month period will result in the family being discharged from our practice.

I acknowledge I was given this information.
Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature*

Powered by Jotform SignClear
Please verify that you are human*
Should be Empty:

Patient and Family Information