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Florida Center for Infectious Diseases
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Florida Center for Infectious DiseasesFlorida Center for Infectious Diseases
(904) 292-086313241 Bartram Park Blvd., Ste. 1001 Jacksonville, FL 32258

13241 Bartram Park Blvd., Ste. 1001
Jacksonville, FL 32258

(904) 292-0863

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  • Welcome to Florida Center for Infectious Diseases. Please fill out this form if you’re a new patient.
    If you're unsure about a question, please mark with a question mark (?) and we will discuss with you at your first appointment. We look forward to serving your needs and helping you accomplish your goals as your new health care provider.



    Patient Information

  • Who is your primary care provider?

  • Patient Information (continued)

  • Responsible Party

  • Certification and Assignment

  • To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health. I certify that I, and/or my dependent(s), have insurance coverage with
  • and assign directly to Florida Center for Infectious Diseases all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. Florida Center for Infectious Diseases may use my health care information and may disclose such information to the above-named Insurance Company (ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below, which ever is longer.
  • Signature of Patient, Parent, Guardian or Personal Representative
  • Date Format: MM slash DD slash YYYY
    Date
  • Please print name of Patient, Parent, Guardian or Personal Representative
  • Relationship to Patient
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

  • Major Surgeries and hospitalizations:

  • STD History: Have you had any of the following? If so, when were you treated?
  • Have you had these vaccinations?
  • Pneumovax
  • Date Format: MM slash DD slash YYYY
  • Hepatitis A
  • Date Format: MM slash DD slash YYYY
  • Tetanus (TDAP)
  • Date Format: MM slash DD slash YYYY
  • Hepatitis B
  • Date Format: MM slash DD slash YYYY
  • Influenza
  • Date Format: MM slash DD slash YYYY
  • Chickenpox or Shingles
  • Date Format: MM slash DD slash YYYY

  • Family Medical History

    Relationship

  • Review of Systems — Check all that apply:

  • General Condition:

  • Respiratory Condition:

  • Gastrointestinal Condition:

  • Musculoskeletal/Skin Condition:

  • Neurological Condition:

  • EENT Condition:

  • Cardiovascular Condition:

  • Genitourinary Condition:

  • Endocrine Condition:

  • Psychiatric Condition:

  • Medications—Please include vitamins, herbs & over-the –counter pills

  • (i.e.. Zyrtec 10 mg Tablet by mouth once per day 10/24/2008)
  • Medication Allergies (check only those allergies which apply)

  • Daily Habits

  • Personal Habits
  • Is there anything else we need to know?
  • This field is for validation purposes and should be left unchanged.
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