Patient Forms
Register Online as a New Patient
Fill out your child’s registration online — about 5–10 minutes. Your information is protected by HIPAA-compliant encryption and is only accessible to our care team. After you submit, we’ll review and reach out to confirm your child’s first visit.
PREFER PAPER?
Technology isn't always easy.
If the online form isn’t working for you, you can download the registration paperwork, complete it by hand, and email it back to our care team — or bring it with you to your child’s first visit.
Email completed forms to: [email protected]
Or call us at (772) 569-3212 and our team will walk you through it.
Notice of Privacy Practices
Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully.
Authorization for Release of Medical Information
Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.
Authorization for Consent for Treatment
All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento.
Preferred Contacts
Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos
Financial Policy
This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.