Forms

*Please click the seal for the NEW PATIENT application*

BEFORE COMPLETING THE NEW PATIENT APPLICATION PLEASE BE ADVISED THAT NEW PATIENT APPOINTMENTS ARE SCHEDULED FOR EVALUATION PURPOSES ONLY.

WE WILL LOOK UP YOUR PRESCRIPTION DRUG USE HISTORY IN E-FORCSE® PRIOR TO PRESCRIBING ANY MEDICATION.

E-FORCSE®, the Florida Prescription Drug Monitoring Program
is a database we use to improve patient care by confirming a patient’s prescription drug history to identify potentially hazardous drug interactions.  As a healthcare provider our goal is to practice safe prescribing while helping to reduce drug abuse and diversion.

Please read the Office Policies before you submit the secure online form.

We ask for this information to begin the process of scheduling your appointment.  Completing this form does not guarantee you an appointment, nor obligate you to book one, it provides information needed to verify your insurance, assess your suitability for this care setting, and confirm your agreement to our no call/no show fee policy.  Once the form is received we will contact you within 72 hours to discuss an appointment.
IMPORTANT – PLEASE ALLOW 3 BUSINESS DAYS BEFORE CALLING US.
If you do not hear from us within that time, call Marie
at 772-678-5797.
Note: The prospective patient must approve submission of this form by another person.  Submitting false information is cause for termination.

CLICK THIS SEAL TO COMPLETE A NEW PATIENT REQUEST FORM

CLICK HERE FOR SECURE FORMTo protect your privacy this form is encrypted for secure transmission.


DOWNLOADABLE FORMS  (Forms will open in a new browser tab)

Patient Forms:
You can help us make your first appointment even better by printing and completing the  forms in the New Patient Packet to bring with you for your initial appointment.

New Patient Forms Packet

Consent to release information

Notice of Privacy Practices



NOTICE:  The following YouScript® forms are OPTIONAL.
To participate in this service, print out and complete the forms and bring them with you.

YouScript®  Forms for pre-screening and requesting genetic tests that can identify your unique medication sensitivities.

YouScript® Risk Assessment Form  – A few questions to find out if testing can help you.

YouScript®  Requisition Form – Get  your testing started.


Technical Note:
PC Users: Our downloadable forms can be viewd and printed using Adobe Acrobat Reader 5 or greater.
Please download the free version from Adobe’s web site if it is not already installed on your system.

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