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.

New patients must review and acknowledge receipt of this information prior to your first visit.

A summary of patient's rights and responsibilities, per Florida Statute 381.026

Please fill out this form to allow your parents or anyone else that you have identified access to your medical information.

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.

As of 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.