For foster parents (patients of any age): this form must be completed by the guardian who will be present for office visits.
For patients 18 years and older: this form must be completed by the patient.
New Patients
This form must be completed by the parent or guardian who will be present for office visits. It covers our financial responsibility policies and notice of privacy practices.
This form contains a representative list of potential fees and charges you may incur, so you are better informed at the time of service, and prior to the arrival of a billing statement.
Please complete this form for your child's first office visit.
New patients must review and acknowledge receipt of this information prior to your first visit.
If you are new to PHCA and your child is age 6 months or older, please bring this completed form to your child's first office visit.
A registration form is required each year to obtain current information for patients and parents.
A summary of patient's rights and responsibilities, per Florida Statute 381.026
Please complete this form to consent to treatment of a minor child, and to identify individuals who may bring your child to the office for treatment. Without this form, we will be unable able to deliver medical service to your child if he or she is accompanied by someone other than the listed parent(s)/legal guardian.
For parents-to-be who would like a prenatal meeting before baby arrives, please complete this short questionnaire to help us get to know you.
Please complete this form to have your child's medical records released to our office, from your child's previous health care provider.
Please complete the attached forms in preparation for your appointment with Pediatric Health Care Alliance.
Starting in early 2023, this statement will be presented to all patients as part of registration. It is our PHCA philosophy regarding the unique challenges and sensitive nature of medical care for children of divorced or separated parents. This is designed to help parents navigate these sensitive areas and avoid misunderstandings during the treatment process.