Patient Pre-Visit form

2010-02-07T14:33:00.000-08:00

Please Cut and paste and fill the form and send it in comments section the following information prior to your next visit:

Parents Name:

Child's name:

Child DOB and Age:

Address:

How to contact you:

Home Phone #

Cell# Text Yes or no

Email:

___________________

Reason for the visit:

Date of visit:

Medications:

Allergy:

Past Medical History:

Vaccines:

______________________

Payment type for the visit:

Cash:

Credit

Insurance Name:

Insured Name and date of birth:

Insurance deductible and Copay to date:

Office Policies

2010-02-07T14:19:00.000-08:00

Iman Bar MD| 359 San Miguel Dr. #200 NB Ca 92660| 949 706 1212

Welcome to Dr. Iman Bar’s Boutique Pediatrics!

Here are a few of our office rules and policies. We would like for you to take the time and read them when you join our practice so that we can serve you better.

Office Hours: Our office hours are 10 a.m. to 4:00 p.m.

The office is closed on Tuesday.

Appointments: Patients are seen by appointment only.

We will attempt to contact you 1-2 business days prior to your appointment as a reminder. If we are unable to reach you, it is still your responsibility to keep the appointment.

For late arrivals, rescheduling may be necessary if you are more than 15 minutes late for your appointment. We will try to work you in if time allows. There will be a full charge for missed appointments or cancellations less than 24 hours.

Each child needing examination by the doctor should have an individual appointment. In general, well examinations cannot be conducted on an ill child.

Payment: The Parent/Guardian of the child must notify the office of changes in address, telephone number or insurance.

You must bring your insurance cards to every visit.

All copay, deductible, and any share of cost is due at time of service.

If we are not able to verify your insurance at time of visit payment in full is required.

All charges not covered by your insurance company are responsibility of the Parent/Guardian. Please contact your insurance company if you have any questions regarding your individual insurance plan.

We accept cash, Visa, Master Card, American Express.

Financial arrangements will be required for outstanding balances within 30 days.

Natural Pediatric, Herbal and Holistic Consults: are available through our practice for an additional consult fee.

Concierge and House Call Services: are available upon request.

Medical Records: Patient copies of the medical record can be obtained for a fee 50 cents per page.

Prescriptions: In the event, the prescription is not picked up and filled; a $15.00 charge will be applied for rewrites. Medication refills can be requested over the phone to treat stable, chronic medical conditions that require ongoing medications, as long as the patient is established and has been seen for the condition within the past 3 months.

Refills will not be provided after hours or on the weekends. Please allow 48 hrs for these refills to be completed. Any prescription refills needed prior to our office policy of 48 hours, will be assessed a $15 fee.

Telephone Calls: If you wish to have a phone consult please be advised there will be a minimum charge fee of $ 50 for calls that can not be billed to the insurance. In case of an emergency, call 911 or take your child to the nearest hospital emergency room.

After-hour Services:

Urgent Calls may contact the Doctor via perfect serve at 877 2115294

Contact with the nurse/physician is intended for urgent medical problems only. Questions about appointments, billing, referrals, refills, or other issues of a non-urgent nature should be placed during normal business hours. Violation of office policies may result in dismissal from the practice. By signing below you acknowledge that you have read and understand the office policies.

Print Patient Name:

Print Parent/ Guardian Name:

Signature Parent/Guardian:_______________________ Date: ________

You may fax this form to (949) 209-0365, e-mail it to newportpediatrics@gmail.com or bring it with you to

Newport Concierge Pediatrics Office forms

Patient Pre-Visit form

Office Policies