Patients

Patient Forms

We know your time matters. Download and complete the forms below before your visit — it helps us get you seen faster and keeps your appointment running smoothly.

Please print each completed form and bring it with you to your appointment. For your privacy and security, do not email these forms to us — standard email is not encrypted and cannot safely transmit your personal health information. Completed forms should not be uploaded or returned to us online.

New Patient Forms

(6 forms)

—Authorization for Release of Medical Record PDF —New Patient Registration Form PDF —Patient Medical History Form PDF —Notice of Privacy Practices (HIPAA) PDF —Financial & Insurance Policy PDF —General Office Policies PDF

Questions about a form? Call us at (407) 402-2303 and we'll walk you through it.

Annual Patient Intake Update — Existing Patients

To keep your chart accurate and your care running smoothly, we ask every existing patient to review and update their intake information once a year. This takes just a few minutes and helps us reach you, bill you correctly, and treat you safely.

Please let us know if any of the following have changed in the last year:

—Insurance carrier, plan, or ID number
—Home address, phone number, or email
—Current medications, dosages, or pharmacy
—Emergency contact or preferred pharmacy
—Any new diagnoses, allergies, or surgeries

Just give our front desk a call at (407) 402-2303 to update any of the above, or complete the form below.

Annual Intake Update Form

Please complete and submit this short form once a year, or any time your information changes. If you'd rather not fill out the form, you're always welcome to call our front desk at (407) 402-2303 instead.

Patient Information

Full Name

Date of Birth

Insurance Information

Insurance Carrier

Insurance Plan / Group Number

Insurance ID Number

Contact Information

Home Address

Phone Number

Email Address

Medications & Pharmacy

Current Medications & Dosages

Preferred Pharmacy

Emergency Contact

Emergency Contact Name

Emergency Contact Phone

Health Updates in the Last Year

New Diagnoses, Allergies, or Surgeries

Notice: Electronic Dictation, AI Documentation & Voice Recording

To help our providers stay focused on you during your visit rather than on typing notes, Access Family Care, LLC may use electronic dictation, AI-assisted documentation tools, and/or voice recording software as part of your care. These tools may listen to and transcribe portions of your appointment to help generate your medical record.

Your information is handled in accordance with our HIPAA Notice of Privacy Practices. You will always be told when a recording or AI-assisted tool is in use, and you may ask your provider to pause or turn it off at any time. If you have questions or would like to discuss this further, just ask any member of our team.

Acknowledge & Sign

Please complete this short acknowledgment once a year, or ask our front desk for a paper copy.

Patient Full Name

Date

Consent

I acknowledge that I have read and understand this notice. I understand that Access Family Care, LLC may use electronic dictation, AI-assisted documentation tools, and/or voice recording software during my visits to help generate my medical record, that this is handled in accordance with the practice's HIPAA Notice of Privacy Practices, and that I will always be told when such a tool is in use and may ask my provider to pause or turn it off at any time. I consent to this use.

Electronic Signature (type your full legal name)

Questions About Your Forms?

712 W 25th St, Sanford, FL 32771

Book Appointment Call (407) 402-2303