Spuza-Milord

Patient Information

Full Legal Name *

Date of Birth *

Social Security Number (optional) Used for insurance verification only. Not required.

Contact Information

Phone Number *

Email Address *

Street Address *

Apt / Suite / Unit (optional)

City *

State *

ZIP Code *

Insurance Information

I do not have health insurance / will be paying out-of-pocket.

Primary Insurance

Secondary Insurance

I understand that I must bring my insurance card(s) and a valid photo ID with me to my appointment. *

These documents are required to verify your coverage. Without them we may be unable to see you at your scheduled visit, so please be sure to bring them — it’s important.

Medical History

Current or Ongoing Conditions

Check all that apply. You may add others in the text area below.

Bone & Skin

Osteoporosis Psoriasis Eczema / Atopic dermatitis

Cardiovascular

Endocrine & Metabolic

Diabetes MAI Thyroid Parathyroid

Gastrointestinal & Liver

Kidney / Urinary

Kidney disease Kidney stones

Neurologic

Blood & Cancer

Anemia Cancer Leukemia

Infectious

HIV / AIDS Tuberculosis COVID-19

Eye

Cataracts Glaucoma Macular degeneration

Allergy & Immune

Environmental allergies (pollen, grass, etc.) Chronic urticaria (hives) Food allergies Drug allergies Immunodeficiency

Other conditions not listed above

Past Surgeries / Procedures

Any previous fractures?

No Yes

Describe

Any other serious injuries?

No Yes

Describe

Drug & Food Allergies

Personal History

The following information helps us understand the lifestyle factors that may affect your care.

Do you smoke?

Yes No In the past

How long ago did you quit?

Do you drink alcohol?

No Yes

Usual drink

How much / how often

Has anyone ever told you to cut down on your drinking?

Yes No

Do you use drugs for reasons that are not medical?

No Yes

If yes, please list

Do you get enough sleep at night?

Yes No

Do you wake up feeling rested?

Yes No

What is your highest educational level?

High school Some college courses College graduate Advanced degree

What is your current or past occupation?

Are you currently working?

Yes No

If yes, hours per week

If no, are you:

Retired Disabled Sick leave

Do you receive disability or SSI?

Yes No

If yes, for what disability?

Date disability began

With whom do you currently live?

How much exercise do you get each week, and what kind?

Family History (click to expand)

If Living

If Deceased

Age

Health

Age at death

Cause

Father

Mother

Number of siblings

Number living

Number of children

Number living

Additional family or personal information

Current Medications & Vitamins

I am not currently taking any medications, vitamins, or supplements.

Please include prescription medications, over-the-counter drugs, vitamins, and supplements.

PHI Authorization

Under HIPAA, you must designate at least one (and up to three) individuals authorized to discuss your protected health information (PHI) with our staff. These are people we may contact or speak with regarding your care (e.g. a spouse, parent, or caregiver).

Authorized Representatives (at least 1, up to 3)

I request that my health information not be disclosed to family members or others, except as required for treatment.

Consent & Agreements

Financial Policy

Payment (co-pays, deductibles, and balances) is due at the time of service.
Patients without insurance are expected to pay in full at check-in.
We will bill your primary and secondary insurance on your behalf.
Unpaid balances remaining after 90 days may be referred to an external collection agency.
A $25 fee applies to returned checks.
Missed appointments without 24-hour notice may incur a no-show fee.

📄 View full Financial Policy (PDF)

I have read and agree to the Financial Policy of this practice.

Form Fee Agreement

Completion of non-standard forms (FMLA, disability, prior authorization, letters, etc.) requires a processing fee.
Fee amounts vary based on complexity; rates are available at the front desk.
All fees must be paid in full before forms are released.
Medical records requests are subject to a preparation fee as permitted by Florida law.
Rush processing may be available for an additional fee.

📄 View full Form Fee Agreement (PDF)

I have read and agree to the Form Fee Agreement of this practice.

Patient Bill of Rights & Responsibilities

You have the right to be treated with courtesy, respect, and protection of your privacy and dignity.
You have the right to a prompt and reasonable response to questions and requests, and to know who is providing your care.
You have the right to information about your diagnosis, treatment, alternatives, risks, and prognosis — and to refuse treatment except as provided by law.
You have the right to impartial access to medical care regardless of race, national origin, religion, disability, or source of payment.
You have the right to a reasonable estimate of charges before treatment and to a clear, itemized bill upon request.
You are responsible for providing accurate health information, following the agreed-upon treatment plan, keeping appointments, and meeting the financial obligations of your care.
You have the right to file a grievance with this practice or with the Florida Agency for Health Care Administration (1-888-419-3456).

📄 View full Patient Bill of Rights (PDF)

I acknowledge that I have received and reviewed the Florida Patient’s Bill of Rights and Responsibilities.

Notice of Privacy Practices (HIPAA)

This practice follows HIPAA regulations to protect the privacy of your medical records, whether paper or electronic.
Your records may be used and shared without separate authorization for treatment, payment, and routine healthcare operations (such as referrals, billing, quality review, and appointment reminders).
Limited disclosures may also be required by law — for example, public-health reporting, court orders or subpoenas, suspected abuse, or workers’ compensation.
This practice does not sell your information and does not use it for marketing. Any other disclosure requires your written, revocable authorization.
You have the right to inspect and copy your records, request corrections, request confidential communications, receive a list of disclosures, and request additional limits on use.
You may file a privacy complaint with this practice (HIPAA Privacy Officer, 5100 Seminole Blvd., St. Petersburg, FL 33708 · 727-319-4543) or with the U.S. Department of Health and Human Services. We will not retaliate for filing a complaint.

📄 View full Notice of Privacy Practices (PDF)

I acknowledge that I have received and reviewed this practice’s Notice of Privacy Practices.

Medical Records Release

Please indicate whether you authorize this office to request your medical records from a previous provider. You must make a selection before continuing.

Comprehensive Authorization — I authorize this office to obtain any and all of my medical records from any healthcare provider or facility as necessary for my care. This includes, but is not limited to, lab results, imaging, provider notes, hospital records, and medication history. This authorization is valid for 12 months from the date of signature and may be revoked at any time in writing. Limited Authorization — I authorize this office to request only specific records from the provider(s) I list below. No — I do not authorize the release of my medical records at this time.

Review & Sign

Please review your information. If anything is incorrect, use the Back button to make changes.

Electronic Signature

By signing below, you confirm that all information provided is accurate, and that you have read and agree to all forms and policies included in this intake packet, including the Registration form, Medical Questionnaire, PHI Consent, Financial Policy, Form Fee Agreement, Privacy Practices notice, and Florida Patient Bill of Rights.

I consent to the use of an electronic signature in lieu of a handwritten signature.

Sign in the box below: *

Use your mouse or finger to draw your signature.

New Patient Intake

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Patient Information

Contact Information

Insurance Information

Medical History

Rheumatologic / Autoimmune

Bone & Skin

Cardiovascular

Respiratory

Endocrine & Metabolic

Gastrointestinal & Liver

Kidney / Urinary

Neurologic

Blood & Cancer

Infectious

Eye

Allergy & Immune

Personal History

Current Medications & Vitamins

PHI Authorization

Consent & Agreements

Medical Records Release

Review & Sign