Self Pay Client Registration

Pediatric Development Center of Atlanta, LLC - Self Pay Client Financial Responsibility Form
Child's Name*

First NameMiddle or Middle InitialLast Name
Child's Date of Birth*

MonthDayYear
Sex*

FemaleMaleOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent 1 Name*

First NameLast Name
Cell Phone Number*
Please enter a valid phone number.
Home Phone Number - Type in Cell Phone Number If You Do Not Have One*
Please enter a valid phone number.
Parent 1 Address (Only If Different From Child's Address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent 2 Name

First NameLast Name
Cell Phone Number
Please enter a valid phone number.
Parent 2 Address Only If Different From Child's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Primary Care Physician*

First NameLast Name
Child's Primary Care Physician Phone Number*
Please enter a valid phone number.
Do You Have A Prescription or Referral*

YesNo
Referred to Clinic By*

PCPWebsiteFriend/RelativeOther
I understand I am financially responsible for services rendered and payment is due at the time of service if requested, or immediately upon receipt of a Billing Statement. I also understand Secure Online Credit Card Payments can be made via the Pediatric Development Center of Atlanta Patient Portal. If there are any changes in address and or contact information, I agree to notify Pediatric Development Center of Atlanta immediately.
Signature*

Clear
Type in Your Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Pediatric Development Center of Atlanta, LLC - Self Pay Client Financial Responsibility Form