INTAKE FORM - CHILD

Thank you for your interest in private medical care. Please fill out the form below to get started. Please note, we only care for children age 13-17 and adults 18+.

NEW PATIENT FORM - MINOR

Please fill out the following form to get started.

First Name of Minor

Email Address

Last Name of Minor

Date of Birth

Select one:

I would like you to bill my insurance, if insurance allows

I have insurance, but prefer to self pay

I do not have insurance. I will self pay.

If you have insurance, provide details below (name of insurance company, policy #, group #, and effective date of policy (if known). BE SURE TO PROVIDE NAME OF THE INSURANCE HOLDER.

Is the child sufferring with a medical condition, illness, or injury? Explain below:

How did you hear about us?

Today's Date

I declare that I am the legal guradian for the child listed above and that the info I’ve provided is accurate. If you are experiencing a medical emergency please call 911.

Successful submission. We will contact you soon.

352-873-3800

INTAKE FORM - CHILD

NEW PATIENT FORM - MINOR

Call today to schedule an appointment!

352-873-3800

After hours and weekend hotline for existing patients