New Patient Required Forms
The following pre-visit forms will help you consolidate your medical history in preparation for your visit to our office. Please either complete these forms online and print, or print them out and fill in by hand. Please bring these forms with you when visiting our office.
You may also fax your completed forms to (239) 278-0404.
New Patient Packet
Every new patient is required to complete this medical history form. Please complete each question. Print out a copy and give to the Receptionist when you sign in for your appointment.
Patient Demographic Profile
Every new patient is required to complete this demographic form. Please provide accurate information. Read and sign the form. Print out a copy and give to the Receptionist when you sign in for your appointment.
Acknowledgment of our Notice of Privacy Practices
Please acknowledge receipt and review of our HIPAA Notice of Privacy Practices. Notice and acknowledgment form can both be found below.
FHA Financial Policy
Please read this information and acknowledge your understanding by signing this document prior to your first appointment.
Request to Obtain Medical Records Form
Form used for Florida Heart Associates to obtain your necessary medical records from another Physician. You will need to print a second copy of these forms if you want to keep a record of this information.
Notice of Privacy Practice – HIPPA Notice
The following notice of Privacy Practices describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this carefully as you will be required to sign an acknowledgment of receipt and review of this notice.
For Your Convenience Only
These forms are not requrired, but provided here for convenience if necessary.
Authorization to Florida Heart Associates to Release Medical Records Form
This form is used to request that Florida Heart Associates release your Medical Records to another Physician. You will need to print a second copy of these forms if you want to keep a record of this information.
