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Haywood Pediatric & Adolescent Associates, P.A. DATE ACCOUNT # Please, fill out each box completely for all children that the following information pertains to. 1st Child's Name: (Last Name) (First

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1. Start by gathering all the necessary documents and information required for the form. This may include personal details, medical history, and any other relevant information.
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4. Move on to the medical history section where you will be asked to provide information about any pre-existing conditions, allergies, medications, and previous treatments.
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7. Sign and date the form as instructed. In some cases, a parent or guardian may need to sign on behalf of a minor.
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Who needs Haywood Pediatric & Adolescent:

1. Children and adolescents who require medical care or treatment from the Haywood Pediatric & Adolescent facility.
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3. Any individual or organization involved in healthcare administration or accessing medical records of patients at Haywood Pediatric & Adolescent.

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