New Patient Forms
NEW PATIENT FORMS
These forms must be completed for all new patients AND any patient that we have not seen in 3 or more years. Complete the form and bring it with you to your first visit.
MEDICAL RECORDS REQUEST
If you would like us to release some or all of your medical records to yourself or another physician, complete this form and fax it to 321-259-4369.
Records Request Outside
Complete this form request medical records FROM another physician's office TO Space Coast Foot & Ankle Center.
Please note that other physician's offices may have their own form they would like you to use.
If your employer requires paperwork to be completed by our office, please complete the attached form and fax it, along with your employer's paperwork, to 321-259-4369.
Allow 72 hours for the paperwork to be completed. If you're preparing a leave due to upcoming surgery, you must have these form to our office 1 week prior to your surgery date.
Please bring the following items to your first appointment:
- Driver’s License
- Insurance Card
- Names and dosages of any medications/vitamins you are currently taking
- Completed Patient Information Documents (Download using the button below)
If you do not have above items completed and with you this may delay your appointment time or result in the need to reschedule your appointment.
- Aetna Healthcare
- Blue Cross Blue Shield (Including Health Options)
- Health First (Classic Plan ONLY)
- Tricare (Standard, Prime, and Tricare for Life)
- United Healthcare
*It is the responsibility of the patient to ensure that our clinic is in network
- Credit Card- Visa & Mastercard
- We also offer discounts to self-pay patients