125 Alison Drive, Suite 5, Alexander City, AL 35010 

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Poision Control - 1-800-222-1222
Our Office - 256-234-4443


THANK YOU FOR CHOOSING US AS YOUR PEDIATRICIAN! We are committed to your successful treatment. Please understand that payment of incurred fees is a part of your treatment. The following is a statement of our financial guidelines, which we ask you to read and sign prior to treatment.


  • All patients must complete our patient information form(s) before seeing the doctor.
  • Full payment is due at the time of service if there is no insurance at the time of the visit.
  • Co-pay is due at the time of service.
  • We accept cash, checks, VISA/MasterCard or Discover. A charge of $30.00 will be assessed for any returned checks.


If you have any questions or concerns we are willing to help at any time. Our staff is here to serve and make your visit as pleasant as possible.


Regarding Insurance

We ask that all insurance patients have active insurance. We will file your claims, handling insurance queries, processing follow-us, lost claims, etc. Please remember that the financial obligation for medical treatment is between you and this office. All co-pays are due at the time of each visit and must be paid before seeing the doctor.

The adult accompanying a minor and the parent-guardian are responsible for full payments.


Missed Appointments

In order to serve our patient's needs and to contain our costs, we ask our patients for a 2 hour notice on cancellation of appointments. Unless cancelled at least 2 hours in advance, our policy is to charge for missed appointments at the rate of $25.00. Please help us to better serve you by keeping scheduled appointments. The doctor works on a timed schedule so failure to appear for an appointment affects many patients. Your cooperation in this matter is greatly appreciated.


Financial Responsibility

In the event of nonpayment of charges for services rendered, I agree to pay all costs of collection including a reasonable attorney's fee, court costs or collection costs and hereby waive all rights of exemption under the constitution of the state in which I reside. I understand the attorney's fee awarded by the court will be based upon all time spent on the case, until the debt is paid in full. I have read this contract and understand its provisions.

Thank you for understanding our Financial Guidelines. Please let us know if you have any questions or concerns. 

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Patient Name                                                                         Date of Birth

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Signature of Parent/Guardian                                                   Date Signed