Secure Intake Patient Registration
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Patient Intake Portal

Centro de Salud Familiar

Norcross Medical Clinic

5836 Buford Hwy Suite C, Norcross, GA 30071

770-734-9920   770-734-9115

[email protected]

Portal status
Ready
Bilingual intake form
Department Family Medicine
Form Type Children Registration
Record Format Printable PDF

Patient registration

CHILDREN REGISTRATION FORM

Validación activa: datos esenciales y firmas requeridas.

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    PERSONAL INFORMATION / INFORMACIÓN PERSONAL
    PARENTS INFO / INFORMACIÓN PADRES
    MEDICAL HISTORY / HISTORIA MÉDICA
    PATIENT TREATMENT CONSENT / CONSENTIMIENTO
    Authorization and release statement

    Autorizo al Consultorio C.D.S.F Norcross Medical Clinic brindar tratamiento médico. Estoy de acuerdo a que se le envié informes a especialistas de ser necesario.

    I release C.D.S.F Norcross Medical Clinic from any and all liabilities resulting from treatment received from this office.

    01

    RECORD RELEASE / ENVÍO DE RÉCORDS MÉDICOS

    Patient or guardian signatureRequired before print
    SIGNATURE (Firma)
    02

    AUTHORIZATION FOR PAYMENT / AUTORIZACIÓN DE PAGO

    Responsible party signatureRequired before print
    SIGNATURE (Firma)
    03

    CONSENT FOR TREATMENT / CONSENTIMIENTO TRATAMIENTO

    Final authorization signatureRequired before print
    SIGNATURE (Firma)