- I understand the importance of regular health supervision for my child(ren) and will follow the recommended schedule of visits: Newborn; 1 month; 2, 4, and 6 months; 9, 12, 15, and 18 months; 2, 2 ½, and 3 years, and yearly after age 3.
- I recognize the importance of protecting my child(ren) and the community from potentially harmful or fatal vaccine-preventable diseases, and agree to have my child(ren) immunized according to the State of Indiana requirements. I am aware that the Vaccine Information Sheets are available for my review, and that copies are available to me upon request.
- I give permission for Dr. Gary Halberstadt, D.O., or his associates, to provide emergency medical treatment for my child(ren) in my absence.
There will be a $25.00 fee for any appointments not kept without at least a 24-hour cancellation notice. Three (3) missed appointments per family may result in a dismissal from the practice.
Parent/Guardian Signature: __________________________________________________
Parent/Guardian Printed Name: _______________________________________________