Patient Forms List
During an emergency you may not be able to communicate effectively with your care provider vital information concerning your medical history. In the case of a dependent, you may be not be available when your child needs immediate medical attention. These forms are designed to validate your wishes and authorize a healthcare provider to give you the care you need in a life-threatening situation.
New Patient Registration Form
Pre-registration can save time for staff as well as patients. Staff members can improve your flow of services at the clinic by ensuring a more complete patient health profile prior to seeing a physician.
Authorization to Treat Form
This Authorization to Treat Form gives a physician permission to treat your child when he or she is in someone else’s care. Filling this out in advance and providing convenient access to it may prove useful for extended family members, babysitters or those providing extra-curricular activities
Medical Records Information Release Form
The medical record information release is included in each person’s medical file. This authorization provides a list of trusted persons or organizations for whom they wish to have made their medical information released. No one is privy, by law, to any of the patient’s information under any circumstances. This includes the ability for healthcare providers to share information among each other. This document may be revoked and/or reassigned at anytime by the patient.
Do Not Resuscitate Form
A "Do Not Resuscitate Form", also known as an “Advance Directive” or "Living Will", allows a patient to advise the processes for their end-of-life medical treatment and care. This document specifically directs physicians to care for a patient based on what is stated in this form, especially with issues such as Do not resuscitate. In the event a patient becomes incapacitated it is too late to determine their end-of-life wishes.
Health Care Surrogate Designation
The ‘Designation of Health Care Surrogate’ form, allows a patient to assign a surrogate and an alternate surrogate to make health care judgments in the unlikely event that he/she (the patient) suffers a medical occurrence whereas they're unable to communicate their desires to a health care provider.
Living Will Directive Form
The "Florida Living Will" is designed to empower the respondent to provide their own specific conditions for when dying is not to be prolonged. The patient proactively under his own volition and understanding is able to determine what is defined as a terminal condition, end stage condition or a persistent vegetative state.