Upload Image Form Patient Name(Required) Date of Birth(Required) MM slash DD slash YYYY Check all boxes that apply:(Required) Insurance Card Secondary Insurance Medical Insurance Card Driver's License Social Security Number Trauma Dental Monitoring Select AllInsurance Card(Required)Accepted file types: jpg, jpeg, png, gif.Secondary Insurance(Required)Accepted file types: jpg, jpeg, png, gif.Medical Insurance Card(Required)Accepted file types: jpg, jpeg, png, gif.Driver's License(Required)Accepted file types: jpg, jpeg, png, gif.Social Security Number(Required)Accepted file types: jpg, jpeg, png, gif.Trauma(Required)Accepted file types: jpg, jpeg, png, gif.Dental Monitoring(Required)Accepted file types: jpg, jpeg, png, gif.Additional NotesConsent(Required) I have had full opportunity to read and consider the contents of the Notice of Privacy Practices. I understand that I am giving my permission to gather, use and disclose my child's protected health information in order to carry out treatment, payment activities, healthcare operations. I give my consent to Dr. Douglas E. LaDue III to take a chart photo of my child. I also understand that I have the right to revoke permission.
