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New Patient Information / Forms:

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Primary care new patient forms


If you are seeing us for direct primary care, these are the forms you need.


1.) New patient membership agreement:

https://drive.google.com/open?id=1aAUXK1L-Vti8u8RI6wbEnP79g-jb0QGN


2.) Recurring payment form:

https://drive.google.com/open?id=1g26sW4cJLwx6wCN89T2KfkNg4IWwyhia


3.) Private Medical Services to a Medicare member (only download and fill out if you are enrolled in Medicare):

https://drive.google.com/open?id=1RyZSdemfRZShAwZbbOQbCtutCvGoWwbc

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Medical cannabis new patient forms

If you are seeing us for medical cannabis, these are the forms you need.


1.) Medical Cannabis intake form:

https://drive.google.com/open?id=1WJ7Wz2_KL-q8O-vbl1ogw6sW6b2CbE4i


2.) HIPAA Privacy authorization form:

https://drive.google.com/open?id=1f6qtbJj31xuUKjif41qnnPFMJq793xgM


3.) Medical Cannabis consent form (I will explain it to you in person at your visit):

https://drive.google.com/open?id=1H5svANa3GAjBC5XlD--DHq-sjJyNJ4jL

Connect

PHONE:  813 - 491 - 4006

FAX: 813 - 491 - 4007

ADDRESS:  Oldsmar Town Center (right above Hennessey's Bar and Grill)

3980 Tampa Rd., Suite 206, Oldsmar, FL 34677

Hours

Wed - Fri:  9:30 am to 3 pm
Sat: 10 am - 1 pm
Sunday: Closed

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