Skip to main content
Pay My Bill
Agreement to Self Pay Form
909-594-3382
Agreement to Self Pay Form
Fairway Children's Medical Group,2707 East Valley Boulevard, Suite 215, West Covina California
Our Clinic
About Us
Our Providers
Contact & Locations
New Patients
New Patient Registration Form
How to Join our Clinic
Forms
Agreement to Self Pay Form
Vaccine Consent without Parent
Medical Release Form
Referral changes/extensions
Medication Refill Form
Services
Overview
Well Child Exam
Immunizations
Newborn Care
Sports Pre-participation Exam
Sick Visits
Telemedicine
Developmental Screening
Chronic Illness
Policies
Office Policies
Vaccine Policy
Athelas Privacy Policy
Notice of Privacy Practice
Televisits
Resources
Overview
FAQs
Testimonials
Blog
Pay My Bill
Agreement to Self Pay Form
909-594-3382
Agreement to Self Pay Form
Patient Portal
close popup
Are you a new or returning patient?*
New
Returning
Child’s First Name*
Child’s Last Name*
Date of Birth*
Sex*
Male
Female
Other
Reason
Well Checkup
Sports Pre-participation Exam
Sick Visit
Need Referral
Appointment Change needed
Other questions
Lab result question
Primary Caregiver Name*
Primary Caregiver Phone*
Primary Caregiver Email*
Secondary Caregiver Name
Secondary Caregiver Phone
Email*
Phone*
Preferred Language
English
Mandarin
Cantonese
Spanish
I have read and agreed to the
Privacy Policy
and
Terms of Use
and I am at least 13 and have the authority to make this appointment.
I agree to receive text messages from this practice and understand that message frequency and data rates may apply..
Submit
Patient Portal
Agreement to Self Pay Form
Request Appointment
Agreement to Self Pay Form
Menu
Home
Agreement to Self Pay Form