Your Visit

Patient Forms


The following are some of the forms you will be required to fill out at your visit.  Please feel free to print these out and have them ready for your visit.  Please bring your insurance card and photo ID to all of your visits.  If you have any prior medical records, please bring these to your visit.

Gynecological Visit:

 

Patient Registration Form

Office Financial Policy

Health Questionnaire English

Health Questionnaire Spanish

Notice of Privacy English

Notice of Privacy Spanish

Notice of Privacy Acknowledgement English

Notice of Privacy Acknowledgement Spanish

Records Release Authorization

Liability Insurance Acknowledgement

 

Obstetrical Visit:

 

NICA Consent Form English

NICA Consent Form Spanish

NICA Pamphlet English

NICA Pamphlet Spanish

Florida Healthy Start Prenatal Screening English

Florida Healthy Start Prenatal Screening Spanish