I hereby authorize DIN NEUROLOGY AND DALLAS ADHD AND HEADACHE SPECIALIST (NEURO CARE LLC) to perform necessary medical examination and testing for the purpose of treatment of my child  {patientName} *           .

I also authorize DIN NEUROLOGY AND DALLAS ADHD AND HEADACHE SPECIALIST (NEURO CARE LLC) to release any necessary medical information pertaining to my child’s examination, diagnosis or treatment, to any facility (including other physicians/clinics, laboratory, hospital or ancillary providers) to which my child may need to be referred. *       

I further authorize DIN NEUROLOGY AND DALLAS ADHD AND HEADACHE SPECIALIST (NEURO CARE LLC) to release any necessary medical information pertaining to my child’s examination, diagnosis or treatment in order to process medical claims, to my insurance carrier. *   

I understand that there will be a virtual medical scribe with Dr. Din in room during my child's appointment. *       

I also understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). *

Parent/Guardian’s Name    First Name *     Last Name *       

Parent/ Guardian Signature Signature *    

Date Date *     

RESTRICTIONS:
If you wish to request a restriction on the release of your child's records per Section IV, Paragraph D of the Notice of Privacy Practices, please complete this section. This section is not required.
I hereby request the following restrictions on the use and/or disclosure of my child's information: 
      
   
SIGNATURES:
By signing below, you acknowledge that you have received Notice of Privacy Practices prior to any service being provided to you by the Practice, and you consent to the use and disclosure of your child's medical information.

Patient's Name     First Name *     Last Name *          

Patient DOB    Date *    

Parent/Guardian Name    First Name *     Last Name *
  
Parent/Guardian Signature Signature *     

Date Date *
   

Thank you for choosing DIN NEUROOGY AND DALLAS ADHD AND HEADACHE SPECIALIST (NEURO CARE LLC). We are committed to building a successful relationship with you and your family. Your clear understanding of our financial and office policies is an important part of that relationship. Below are the key points. For the full version of this policy, click here.

1) We are committed to understanding your benefits and providing you with a cost estimate for your care before your appointment
2) Before your appointment, please inform us of any changes to your information such as name, address, phone numbers and/or insurance information.
3) We will collect for today’s care and any outstanding balance when you check in.
4) If you miss your appointment or if you cancel or reschedule an appointment within 1 business day, we may charge a late cancellation fee of $50.
5) Please let us know if you are running late to your appointment.
6) Paperwork such as FMLA, and Disability will be charged $50, to be paid in advance
7) By default, you will receive text messages and/or call for appointment reminders and information about your health care treatment
By signing below, you acknowledge that you were given the option to review the full Financial and Office policies document before signing, and you agree to the policies detailed in the full policy.

Patient Name    First Name *     Last Name *    

Patient DOB    Date *    

Parent/ Legal Guardian Signature    Signature *    

Date      Date *    

I understand and agree that if I don’t have insurance coverage, I am expected to pay charges in full at the time, services are rendered.

Patient Name  First Name *     Last Name *    

Patient DOB    Date *    

Parent/Guardian Name    First Name *     Last Name *    

Parent/Guardian Signature    Signature *    

Date    Date *