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Enter your child's basic information below. All medical information will be automatically filled in for you.

First Name *

Last Name *

Date of Birth * Format: MM/DD/YYYY (will be converted automatically)

Parent/Guardian Email * If this email matches our records, the completed form will be sent to this email. Otherwise, it will be sent to the office only.

HIPAA Authorization & Consent

I hereby waive my HIPAA privacy rights and authorize Dr. Simai's office to email my completed medical form to the email address I have provided above.

I understand that email transmission may not be secure and I accept the risks associated with electronic transmission of my medical information.

I request that my completed medical form be sent to me via email and I understand that the office will also receive a copy for their records.

I acknowledge that I have read and understand this authorization and I am signing it voluntarily.

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