• 13241 Bartram Park Blvd., Suite 1001, Jacksonville, FL 32258
    Telephone: (904) 292-0863 Fax: (904) 212-0884

  • Cancellation / No-Show Policy

  • In order to be respectful the medical needs of the community, please be courteous and call our office promptly if you are unable to attend an appointment. We require at least a 24 hour notice so that your appointment time can be reallocated to someone else. Patients who fail to provide 24 hour notice of cancellation or who do not show up for an appointment will be charged a $50 no show/ cancellation fee. This fee is not covered by your insurance company.

    I have read and understand the cancellation and no show policies of the practice and agree to the terms.

  • Printed Name
  • Date Format: MM slash DD slash YYYY
    Date
  • Signature

  • Pharmacy Preferences

  • Please fill out information for where you would like your prescription sent.

  • Pharmacy Name
  • Pharmacy Phone

  • NOTICE OF PRIVACY PRACTICES

  • I acknowledge that I was provided a copy of the Notice of Privacy Practices dated December 2, 2019 and that I have read them or declined the opportunity to read them and understand the Notice of Privacy Practices. I understand that this form will be placed in my patient chart and maintained for six years.
  • Patient Name
  • Date Format: MM slash DD slash YYYY
    Date
  • Parent, Guardian, or Patient's legal representative

  • Patient Information Release

    List below the names and relationship of the people to whom you authorize the practice to release PHI (HIPAA's Protected Health Information)