eStatement Form

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An eStatement is a digital statement sent to you monthly in lieu of a paper statement. Help us save a tree by setting up your eStatement today!
  • any child is fine if you have multiple children
  • where you would like to receive your eStatement
  • optional

If you do not open your email after three (3) days, the system will send you a second eStatement to the above address. If that eStatement is not opened after three (3) days, a paper statement will be mailed to your address on file.

By submitting this form, you authorize Carmel Pediatrics, LLC to send you eStatements once a month should you have a balance. You understand that you will not receive paper statements unless you do not open your email after six (6) consecutive days.