New Patient Registration & Consent Packet

All signatures on this document are required.

Email addresses provided above will be used to send registration forms, appointment reminders, and secure communications from the office.

List additional persons who may bring the child(ren) to appointments or with whom we are authorized to communicate for medical information.

• 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 directly 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 the 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.

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

We understand that there has been a lot of recent discussion regarding vaccine safety and scheduling. Our providers are open and happy to discuss any questions or concerns you may have about vaccine hesitancy or the recommended schedule.

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.

If I choose to NOT have my child vaccinated according to these recommendations, I 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. "I understand that delaying, spacing out, or declining vaccines may leave my child at increased risk for vaccine-preventable diseases during the period they are not fully immunized, and I accept full responsibility for that risk. I release Southwest Pediatrics, its providers, and staff from liability for any illness, complication, or adverse outcome resulting from my choice to follow an alternative schedule or decline vaccination. I acknowledge I was given the opportunity to discuss the risks and benefits of this decision with my child's provider before signing."

If you selected No, please ask the receptionist for the refusal-to-vaccinate form.

This section allows you, as parent/guardian, to give consent in advance for your child to be seen and treated when you are unavailable to bring them to the appointment yourself — for example, when a grandparent, relative, babysitter, or other trusted adult brings your child to Southwest Pediatrics on your behalf. Only those listed in emergency contacts will be allowed to bring the child.

I do hereby consent and authorize Southwest Pediatrics and its providers and staff to examine and/or treat my child in my absence. 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.

As the parent/guardian of the patient, you may request that our office communicate with you by unencrypted email. We will make every reasonable effort to honor that request; however, we reserve the right to decline email communication when we determine it would not be in your best interest.

Please review the following risks before consenting:

• Risk of unauthorized access by a third party — for example, a shared computer or email account, employer-provided email access, an unsecured Wi-Fi connection, or a mobile device that others can access. Email may also be misdirected, intercepted, or altered in transmission.

• Difficulty verifying the sender — email can be easier to forge than a handwritten or signed document. We will only send messages to the email address you provide, but we cannot fully confirm that you are the person accessing that address.

By signing below, you acknowledge these risks and consent to receive unencrypted email communications from Southwest Pediatrics despite them. Messages containing clinically relevant information may be incorporated into the medical record at the provider's discretion. You also acknowledge that you may choose to receive communications through other, more secure means (such as by telephone), and you agree to hold Southwest Pediatrics harmless for unauthorized use, disclosure, or access of protected health information sent to the email address you provide.

If signed by someone other than the parent, please state your relationship to the patient and your authority to act on the patient's behalf.

Southwest Pediatrics offers phone-based (audio-only) telemedicine visits for certain diagnosis, therapy, follow-up, and education needs. As with any phone call, there's a small chance of technical issues or a security lapse, and a phone visit isn't a replacement for an in-person exam when your provider feels one is needed. You're always free to request an in-person visit instead, and you can change your mind about using telemedicine at any time. Doing so won't affect your child's care.

I have read and understand the information provided above regarding telemedicine. I hereby give my informed consent for the use of Audio-Only telemedicine in my child's medical care.

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 (text/SMS)

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.