Patient Forms

Medical Forms

We make it easy by providing all the forms you need, in one place.

ADVANCED HEALTHCARE PLANNING (YOUR WISHES)

Your Wishes Video

• Designation of Healthcare Surrogate Form | En español
• Living Will Forms | En Español
• Organ Donor Form | En Español
• Questions About Advanced Healthcare Planning | En Español
• Wallet Card Forms | En Español
• Your Wishes | En Español

ALLERGY & ASTHMA

• Allergy & Asthma New Patient Questionnaire | En Español

BRANDON & RIVERVIEW FAMILY MEDICINE

Drs. Cheeseman, Dawson, Sarquis, Malibiran, Jiang & Zaccari

• Additional New Patient Forms Packet
• Notice of Privacy Practices | En Español
• Patient Registration Forms | En Español

DERMATOLOGY

• Dr. Diana Calderone – Patient Forms
• Dr. Rachel Careccia and Dr. Felicia Hall – Patient Forms
• Dr. Lowella Esperanza, Dr. Florence Nappi and Dr. Maria Hicks– Patient Forms
• Dr. Michael Montuno – Post-Op Wound Care Forms

ENDOCRINOLOGY

• Diabetic Patient Record | En Español
• General Endocrinology Forms

FAMILY MEDICINE

Dr. James Sotrop

• Health History Questionnaire

Dr. Cicily Stanton

• New Patient History
• Annual Wellness Forms

GASTROENTEROLOGY

Drs. Cody, Feldman, Gandle, Gilbert, Maldonado and Prieto

• Cancellation Policy
• General Gastroenterology Forms

Drs. Heiman and Shepard

• Cancellation Policy
• Patient Forms GI
• New Patient Questionnaire

INTERNAL MEDICINE

• Health Questionnaire Forms
• Office Policy Forms

INTERNAL MEDICINE – DALE MABRY

• New Patient Packet | En Español

INTERNAL MEDICINE LUTZ

• New Patient Packet

INTERNAL MEDICINE ZEPHYRHILLS

• Patient Personal History & Health Assessment

INTERNAL MEDICINE & PEDIATRICS

• Welcome to Internal Medicine & Pediatrics
• Adult History Forms
• Pediatric Health History Forms

NEPHROLOGY

• New Patient Forms

NEUROLOGY TAMPA

• New Patient Form

NON-INTERVENTIONAL PAIN MANAGEMENT

• Dr. Somori’s Forms

NONOPIOID PAIN TREATMENT

• Nonopioid Alternatives for Treating Pain Brochure

OPHTHALMOLOGY

Florida Eye Center – Drs. Allen and Thomas Pusateri

• New Patient Paperwork

Dr. Marianne Diego-Wright

• New Patient Forms
• Authorization to Share Protected Health Information

ORTHOPAEDIC

• Cervical Forms
• General Orthopedic Forms
• Lumbar Forms

ORTHOPAEDIC – SOUTH TAMPA

• Notice of Privacy Practices | En Español
• Patient Registration Forms| En Español
• Medical History Form

OTOLARYNGOLOGY – EAR, NOSE, AND THROAT

Dr. Lance Meyerson

• New Patient Registration Packet | En Espańol
• No Show Fee Policy
• Perfume and Smoke Policy
• Procedure Consent Form

PATIENT REGISTRATION

• Notice of Privacy Practices | En Español
• New Patient Registration Forms | En Español

PSYCHIATRY

Dr. Barkat Khan

• Authorization to Communicate via Electronic Means
• Authorization to Disclose PHI
• Controlled Substances
• Generalized Anxiety Screening
• Mood Disorder Questionnaire
• Personal History Assessment
•  PHQ-9 Form
• Privacy Practices

PSYCHIATRY – MIND-BODY INTEGRATED

Dr. Maulik Trivedi

• • Adult Pre Evaluation Forms
  • Child Adolescent Pre Evaluation Forms

PULMONOLOGY TAMPA

• New Patient Paperwork

RHEUMATOLOGY

Dr. Amarillis Torres

• New Patient Forms

Drs. Faith, Rivera, Rodriguez-Velazquez, Fierro and Gonzalez

• New Patient Forms | En Español
• New Patient Osteoporosis Form
• New Patient Arthritis Form

SURGERY TAMPA

• Patient Registration
• Patient History
• Surgery History

UROLOGY TAMPA

Female Forms

• Authorization to Share Protected Health Info Forms
• Consent for Purposes Forms
• Health History Forms
• Patient Registration Forms

Male Forms

• Authorization to Share Protected Health Info Forms
• Consent for Purposes Forms
• Health History Forms
• Patient Registration Forms

AUTHORIZATION TO CONSENT TREATMENT OF MINOR PATIENT

• Unaccompanied Minor Consent Form | En Español

AUTHORIZATION TO COMMUNICATE VIA ELECTRONIC MEANS

• Communicate PHI Via Electronic Means