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Patient Office Policies Agreement Form

We, at Desert Ridge Children’s Center, strive for excellent patient care in a nurturing environment. We want to maintain an environment that is nice looking, clean, safe and yet enjoyable to our patients. Please read the following established office policies and sign at the bottom, acknowledging your understanding.

· No food or drinks are allowed in the waiting area or exam rooms.

· Individual attentive medical attention plays an important role in your child’s well being. Children’s behavior can be unpredictable and if you are out-numbered, controlling them can be difficult. We ask that you try to make a 1:1 child/adult ratio when visiting our office. This will make your visit with the doctor more beneficial

· No children shall be left unsupervised by an adult in the waiting area. We are not responsible for any injuries incurred while in our office.

· Please do not leave any personal belongings in the waiting area. We will not be responsible for lost or stolen personal belongings.

· Please turn off all cell phones and/or pagers during your visit with the doctor. Individual uninterrupted attention is very important when it comes to your child’s health.

· Any intentional damage done to decorations, furniture and/or office equipment will not be accepted. Parent will be financially responsible for any repair fees, to be determined by the office manager.

· Good communication is always crucial between the patient and doctor. We will try to make a courtesy reminder call the day before any future scheduled appointments. Do not depend on our call as a reminder; you are still responsible for keeping your child’s appointments when scheduled. Please let us know which communication method you would prefer.

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Phone Number Email Address

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Emergency Contact Person Phone Number

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Parent and/or Legal Guardian Signature Date

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Witness Signature Date