I understand that I am financially responsible for all professional charges that my children may incur.

I hereby request and consent that medical treatment be provided to my child.

All copayments and non-covered charges are due at time of service. All costs not paid by insurance are due upon receipt of statement.

I hereby authorize payment of medical benefits direct to Southwest Pediatrics. I further authorize the release of any medical information necessary for processing the insurance claim. I understand that all costs not paid by insurance are my responsibility unless otherwise prohibited by state or federal regulations.

Permission to Treat Minor (under age 18): In the event of an emergency and I cannot be contacted, I give my permission to Southwest Pediatrics to treat my child in their office as required by the events of that emergency situation.

Acknowledgement of receipt of HIPAA Notice of Privacy Practices: I have received or have been given the opportunity to receive a copy of HIPAA Notice of Privacy Practices for Southwest Pediatrics.

The Child is not presently a subject as part of a Domestic Relations (Divorce/Custody) or other lawsuit (either open or closed, Temporary Orders, Final Orders, Continuing Jurisdiction over Child, etc.) and I promise to immediately advise Southwest Pediatrics in the event the Child should become a subject of any of the foregoing legal items. I further promise to immediately provide Southwest Pediatrics a true, complete and correct copy of any filings or orders affecting or that could affect the Child in such a lawsuit. I agree to indemnify and hold harmless Southwest Pediatrics, its owners, professionals, and employees from any and all claims and causes of action, including, but not limited to any Attorney Fees, costs, and expenses, incurred by Southwest Pediatrics, its owners, professionals, and employees as a result of treating or not treating the Child based upon Southwest Pediatrics interpretation or lack of knowledge of the existence of any such legal activity.

If the Child has been seen prior to or during the period of the Child being a patient at Southwest Pediatrics by another Healthcare professional or entity I agree to immediately notify Southwest Pediatrics prior to or at the time of any visit to Southwest Pediatrics and to promptly obtain all medical records from such other Healthcare professional or entity immediately upon the request of Southwest Pediatrics. I further agree to timely and faithfully keep all appointments with such other Healthcare professionals or entities and have all such other tests as recommended by said other Healthcare professionals or entities. I further promise to immediately notify all other Healthcare professionals or entities which the Child has seen or is seeing or starts to see that the Child is also seeing Southwest Pediatrics and request that they speak with Dr. Shagufta Mohi about my Child and how each Healthcare professional or entity may need to interface. I agree to indemnify and hold harmless Southwest Pediatrics, its owners, professionals, and employees from any and all claims and causes of action, including, but not limited to any Attorney Fees, costs, and expenses, incurred by Southwest Pediatrics, its owners, professionals, and employees arising out of even a minor breach and/or failure on my part to strictly comply with this paragraph.

I give my permission for Southwest Pediatrics to treat my child, _____ (Please Print), according to the standards of care defined by the American Association of Pediatrics (AAP) and the realm of medical necessity as deemed appropriate by the treating Provider.

I hereby understand that the physicians at Southwest Pediatrics, The American Academy of Pediatrics, the American Academy of Family Physicians, and the Centers for Disease Control and prevention all strongly recommend that vaccines be given according to recommendations.

Please circle if you would like for your child to be vaccinated?

If I choose to NOT have my child vaccinated according to these recommendations I, _____ (Please Print), thereby take full responsibility and understand that failure to follow these recommendations about vaccinations may endanger the health or life of my child and others with whom my child might come into contact with.

I, _____ (Please Print), do hereby consent and authorize Southwest Pediatrics and it's providers and staff to examine and/or treat my child in my absense. I affirm that I have the legal right to consent to this. I understand that this consent is legal and binding until specifically revoked by myself or another person who has the legal right to sign or revoke authorization. I give the providers and staff permission to treat my child in my absence with whatever treatment plan they deem necessary and appropriate.

I understand that Southwest Pediatrics may provide medical services using telemedicine technology when appropriate. Telemedicine may include video, audio, electronic transmission of medical information, or remote review of medical data.

I understand:

• Telemedicine is voluntary and I may request an in-person visit when appropriate

• The same privacy protections apply as with in-person visits

• Technical difficulties may occur

• Not all conditions are appropriate for telemedicine

• The provider may determine an in-person visit is necessary

• I consent to telemedicine services when deemed appropriate by my provider.

I acknowledge telemedicine services have been explained to me, including risks, benefits, and alternatives. I may have previously provided verbal consent for telemedicine visits. By signing below, I confirm my understanding and provide written consent for telemedicine services, including prior services when applicable and future services when medically appropriate.

I authorize Southwest Pediatrics to communicate with me regarding my child's care, appointments, billing, and care coordination using the contact information I provide.

This may include:

• Phone calls

• Voicemail messages

• Email communication

• Electronic messaging

• Patient portal communication

I understand:

• Standard message/data rates may apply

• Electronic communication may have inherent privacy risks

• I may revoke this authorization in writing at any time

• Electronic communication should not be used for emergencies

I acknowledge it is my responsibility to notify the office of any changes to my contact information.

Emergency Communication Disclaimer:

Electronic communication is not monitored continuously and should not be used for urgent or emergency medical concerns. Call 911 or seek emergency care if needed.

Southwest Pediatrics may use secure artificial intelligence (AI) technology to assist providers with clinical documentation.

I understand:

• AI is used only to assist with documentation

• AI does NOT make medical decisions

• My provider reviews and approves all documentation

• AI does not replace clinical judgment

• All information remains protected under HIPAA privacy regulations

• AI tools used are HIPAA compliant

I understand my provider remains fully responsible for my child's medical care.