The information obtained from the following forms are necessary for us to provide you with the highest quality of care. Your doctor will review this information prior to your visit in order to have a clear understanding of your history and the reasons for your visit. Please give yourself 15-20 minutes to complete and submit the following forms prior to your first appointment. Closing the browser or disconnecting prior to submitting your results at the very end will cause all responses to be lost.
All information disclosed in these forms is part of your psychological record and thus is confidential, as dictated by the Health Insurance Portability and Accountability Act (HIPAA), and the rules and regulations from the State of Florida
Patient Demographic Information
Nickname or Preferred Name
City, State, Zip
Date of Birth
Primary Care Physician
Single, never married
Married or domestic partnership
Native American/American Indian
Employer Phone Number
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