Welcome Letter

We are honored that you have chosen us as your health care provider. We have exciting news regarding your health management with our practice.

As we continue our efforts to provide our patients with the highest quality of care, we are constantly looking for methods together with our patients to ensure that you are not only aware of, but also involved in the management and improvement of your health.

We are proud to inform you that our practice now offers the opportunity to use the power of the World Wide Web to track the most important aspects of your health care through our office. Our Patient Portal enables our patients to communicate with our doctors, nurses, and staff members easily, safely, and securely via the Internet.

Participating patients are given secure User IDs and passwords, enabling them to access the Patient Portal to view their personal and private documents, including labs and diagnostic test results, educational information, billing statements, and other health information.

Through the Patient Portal, you are able to:

Ask questions to doctors, nurses, and staff members
Request refills and referralsSchedule appointments
View your personal health records
Examine your current and past billing statements

. . . all from the comfort of your home, whenever it is convenient for you!

By using the Patient Portal, you no longer have to call the office, leave a message and wait for the return call to get the results of your test; those results will be available to you through the Patient Portal. You can also send a message to the office through the portal and get a prompt reply.

To learn more or to sign up, contact our office today at:

(352) 268 - 0003

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Mobile Phone

Work Phone

Email*

Date of Birth*

Gender*

Marital Status*

Employment*

Military Status*

Employer (If Applicable)

Occupation

Emergency Contact Name

Relationship

Phone

Emergency Contact Name

Relationship

Phone

Were you referred by someone?*

Yes

No

Referred By

Phone

Do you have a Primary Care Physician?*

Yes

No

Primary Care Physician

Phone

Pharmacy*

Phone*

Fax

Pharmacy

Phone

Fax

Language Preference*

Please specify the language

Ethnicity*

Race*

White

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Pacific Islander

Residence Type*

Your Birth Order*

Insurance Information

Relationship to Patient*

Name

First Middle Last

Gender

Date of Birth

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Primary Insurance Company Name

Insurance Address

Phone

Insured Name

Employer Name

Policy Number

Group Number

Copay $

Notice of Privacy and Authorization Form

I acknowledge that if a copy of my personal information is needed for reasons other than immediate treatment, I hereby authorize the release of information to the following: family member, providers, or friends acting on my behalf:

Name

Phone

Relationship

Name

Phone

Relationship

Name

Phone

Relationship

Name

Phone

Relationship

Please choose one of the following options below*

I understand that I may amend this authorization at any time, until then this form will be kept on file until further changes are made. I also understand that any other request for personal health information by another other than those listed will require additional authorization by me in writing.

I refuse to have any information be release to anyone, this include: Family members, Providers, or friends, acting on my behalf.

Welcome Letter

(352) 268 - 0003

Insurance Information

Surgical History

Notice of Privacy and Authorization Form

Authorization for Treatment / Release of Information

Patient Consent for Use and Disclosure of Protected Health Information

The below questions are required to be asked by State Law for Census

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