Patient Forms

For your convenience and faster service, you can download our new patient form and fill it out before attending your first appointment.

Patient Registration Forms

To be completed for all new patients (Three forms are needed):

Registration Form

Policies and Consents

New Patient Health History Form

All patients must bring in their insurance card and photo ID.

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To be completed for all established patients with changes to name, address, or insurance information:

Registration Form

All patients must bring in their insurance card and photo ID.

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To be completed for all established patients who have not been seen in last 6 months or who are scheduled for annual GYN exam:

Established Patient Health History Form

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To be completed if patient is a minor:

Consent for Treatment of a Minor Patient

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For your convenience, we have included a medication list that you may complete and keep with you in your pocket or purse. Keep it updated and take it to all your doctor appointments!

Patient Medication List

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If you would like to have your medical records sent to us prior to your visit, please complete and sign the form corresponding to the location you will be visiting:

Release of information – Village Blvd office, West Palm Beach
OR
Release of information – Palms West office (next to Palms West Hospital), Loxahatchee

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The above forms can be completed, signed and faxed to 561-683-5024. Otherwise, completed forms should be brought to your scheduled appointment.

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These forms are for new or established patient reference only:

Patient Rights and Responsibilities

Notice of Privacy Practices

Aviso Sobre Las Practicas De Privacidad

These forms require Adobe Reader. If you do not have Adobe Reader, you may download it free here:

(this link opens a new browser window).