COVID PROTOCOL: please print and complete each of these forms prior to your visit. Please bring the completed forms with you and present them to the front desk upon your arrival for your appointment.
New Patients: please print and complete each of these forms prior to your visit. Please bring the completed forms with you and present them to the front desk upon your arrival for your appointment.
New Patient Packet
Patient Medical History
Review Of Systems
Permission For Verbal Communication
Consent For Treatment
Patient Private Pay Waiver
Medicare Advance Beneficiary Notice of Noncoverage (ABN)
Established Patients: please print and complete each of these forms prior to your visit. Please bring the completed forms with you and present them to the front desk upon your arrival for your appointment.
Established Patient Packet
New and Established Patients: If you have not yet enrolled in our Chronic Care Program, use these forms to do so. The CCM Program offers improved coordination of your care between office visits, therefore reducing inpatient stays.
Chronic Care Management Explanation Letter
Chronic Care Management Referral Packet
Chronic Care Management Promise Program Enrollment Form
New and established patients: If you need your records sent to another physician, or if you want a copy, fill out the RELEASE portion. If you need your records sent to us, fill out the OBTAIN portion.
Authorization to Release and/or Obtain Health Information
Our Physicians encourage you to have allergy testing. Our allergy clinic is every other Friday from 9am -1pm. Please contact our office 772-283-4428 Ext. 4, and ask to speak to Dorris. We can schedule your allergy testing today. Print this packet, bring it with you to your Allergy Test or email it to frontoffice@pimadocs.com.
Allergy Clinic Consents
Allergy Clinic Questionnaire
Allergy Treatment Brochure
Dedicated to helping patients talk about their wishes for end-of-life care is important to us. We believe that the place for this to begin is at the kitchen table – not in the intensive care unit with the people we love before it is too late. Together we make these difficult conversations easier. We can make sure that your wishes and those of our loved ones are expressed and respected.
Please complete the packet below. Call our office at 772-283-4428 Ext. 4, to schedule your ACP visit. Please make sure you bring the completed packet to your ACP visit. This visit is separate from a regular office visit and needs it’s own time to ensure all your wishes are documented as you want.
In its simplest form, Remote Patient Care Monitoring (RPM) involves the use of connected electronic tools that record personal health and medical data in one location. A provider then reviews the data when there is an abnormal trend. Parameters goals are set for each patient when they are enrolled. Health systems utilize RPM services to treat acute and chronic conditions and are not limited to clinical improvements alone. The care modality can also help break down hurdles related to social determinants of health, that is, social factors that negatively affect health.
To enroll, you have two convenient options available. You can either print the provided form, fill it out, and bring it in person, or simply give us a call at 772-283-4428 Ext.7. We are ready to assist you with your enrollment process.
Annual Wellness Visits are different from your annual appointment with your provider. They can be combined into one trip to the office however, they require different elements to be completed. The AWV packet is given out at the front upon your arrival however, if you want to print the packet and have it completed before your arrival you may do that as well. The AWV is not a head-to-toe physical that you have done yearly. This is in addition to and requires the below packet to be completed.
Annual Wellness Visit Form
