Patient Forms

Pediatric New Patient Packet

If your child is a new patient at Child Neurology Clinic, then please fill out the packet below. 

Neurology Treatment

In addition to treating pediatric neurology cases, we also treat some adults for specific disorders.

Appointments

We have a strict 15-minute late policy. Patients that arrive 15 minutes after their appointment
will need to be rescheduled. A 24‐hour notice is required to cancel an appointment.

Insurance Authorization

It is the responsibility of the patient to ensure prior insurance authorization for all
follow‐up appointments and procedures.

Professional Fees

Payment is due in full at the time of services unless a prior arrangement has been made.
Payment of insurance deductible and insurance co‐pays are due at the time of service. As a courtesy, we will file for all insurance companies. Payment is due in full by the 30th of the month. 

Adult New Patient Packet

If you or a loved one is a new patient at Child Neurology Clinic of Northwest Florida and you are above the age of 18, then please fill out the packet below. 

Neurology Treatment

In addition to treating pediatric neurology cases, we also treat some adults for specific disorders.


Appointments

We have a strict 15-minute late policy. Patients that arrive 15 minutes after their appointment
will need to be rescheduled. A 24‐hour notice is required to cancel an appointment.


Insurance Authorization

It is the responsibility of the patient to ensure prior insurance authorization for all
follow‐up appointments and procedures.


Professional Fees

Payment is due in full at the time of services unless a prior arrangement has been made.
Payment of insurance deductible and insurance co‐pays are due at the time of service. As a courtesy, we will file for all insurance companies. Payment is due in full by the 30th of the month.