Patient Information


Please provide the names, sex, and DOB of all siblings.

Mother/ Primary Guardian

Father/Secondary Guardian

Emergency Contacts

Please list (2) emergency contacts that we can notify in the event that parents/guardians are not available.


Pleae note that we accept most major PPO plans (United, Cigna, Aetna, Blue Cross, Blue Shield).

Medical Consent Form for Child

If you anticipate that your child will be transported and supervised by individuals that are not the parents when visiting the office, then please complete the form below.

Please list the NAMES and RELATIONSHIP to patient for all authorized individuals below:

Telemedicine Consent Form

HIPAA Consent Form

I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.


Our office requires that a credit card be kept on file for payment of any co-payment, co-insurance, deductible, or charge that may not be covered by your health insurance. This form will be kept confidential and only authorized staff has access to the information.

I acknowledge and authorize Sam Kim Physician Services, Inc to charge the above credit card account for any co-payment, co-insurance, deductible and/or charges not covered by my health insurance provider. I acknowledge that my card will be run in the event payment is not received within thirty days after I receive a statement. I agree to receive billing statements, invoices and receipts via the email I have provided to this office. If I am an uninsured patient I authorize payment at time of service. I agree to update any information regarding this credit card account.


Cancellation Policy