enter without dashes
Main Contact Number
If a Legal Guardian we will require Guardianship Papers upon arrival for the appointment
Complete if different from child's address. Otherwise may leave blank.
We may sometimes use email for general communication such as appointment reminders. In such cases, we will use the primary parent/legal guardian's email address.
If different from addresses above.
If your child is self-pay,
enter your name as guarantor
If your child does not have health insurance - enter
Frequently placed on back of insurance card
In the event there is no response at this number -
we will use the other numbers indicated above