Florida Internal Medicine

Available Forms

1. NEW PATIENT MEDICAL HISTORY 2. INSURANCE & DEMOGRAPHICS - for all patients 3. ESTABLISHED PATIENT MEDICAL UPDATE 4. WEIGHT LOSS QUESTIONS - Nicole APRN only

2. INSURANCE & DEMOGRAPHICS - for all patients

Please fill out this form on-line, and then send to us by clicking Submit Form at the bottom of this page. DO NOT PRESS ENTER UNTIL YOU FINISH THE ENTIRE FORM. If you prefer to download the form to submit written answers, please click Home in the upper left, and use the "DOWNLOAD FORMS" link on the Home page.

Today's date *

(mm/dd/yyyy)

Name *

first name, middle name or initial & last name

Sex *

Male

Female

Date of birth *

(mm/dd/yyyy)

Social Security Number

Social Security numbers are transmitted through our secure portal.

E-mail address (optional)

E-mail address is not released to third parties.

Street address *

City *

State *

ZIP Code *

Home phone

please include area code

Work phone

please include area code

Cell phone *

please include area code

Preferred phone(s) to contact you *

Home

Work

Cell

Were you referred by another person or doctor's office?

Please let us know who referred you.

What is your occupation?

If you are retired or unemployed, what was your previous job?

Please enter your employer, work address and telephone number.

Marital Status

Married

Single

Divorced/Separated

Widowed

If you are married, enter the information below:

Spouse's name

Spouse's telephone number

Please include area code

Spouse's date of birth

Spouse's Social Security Number

This information is transmitted securely by our patient portal.

In case of emergency, person to notify, other than spouse.

Please include name, relationship and contact information including phone number.

Primary Insurance Information

Name of insurance company *

or state "NONE"

Policy Number

Group Number

Who holds the policy?

For example, yourself, your spouse or another person (please name).

Secondary Insurance Information

Name of Insurance Company *

or state "NONE"

ZIP Code

Policy Number

Group Number

Who holds the policy?

for example yourself, your spouse or another person (please name).

Advanced Directives

Name, telephone & relationship of someone who can make medical decisions for you if you are unable: *

Have you prepared any of the following documents? *

Living Will

Durable Power of Attorney for Healthcare

Designated Healthcare Surrogate

None of these

Please provide us with a copy of any of these Advanced Directives.

Please bring a PHOTO ID and your INSURANCE CARDS to the next office visit.

You will be asked to sign a copy of our Office Policies, Medical Records Release, Insurance Assignment, Release of Information, and Physicians Insurance Agreement in the office at your next appointment. Thank you for providing this information.

* Required field