Cocoa Beach (321) 784 5437
Melbourne (321) 724 5437
Rockledge (321) 636 3066

Forms & Policies

New Patients

Patient Information Form (PDF)
HIPAA Form (PDF)
Medical Release Form (PDF)
Consent for Treatment (PDF)

Office Policies

Privacy Policy (PDF)
Financial Policy (PDF)
Vaccine Policy (PDF)
Notice Informing Individuals about Nondiscrimination (PDF)
Grievance Procedure Policy (PDF)

18 Years +

18+ Registration Form (PDF)
18+ Financial Policy Form (PDF)
Consent-to-Release-PHI

ADHD Forms

Initial Evaluation – Parent (PDF)
Follow-Up Evaluation – Parent (PDF)
Initial Evaluation – Teacher (PDF)
Follow-Up Evaluation – Teacher (PDF)

Sports Participation Forms

FHSAA-Participation-Physical-Form-(EL2)-2019
FHSAA-Consent-Forms-(EL3)
Brevard-Public-Schools-ECG-Newsletter-and-Consent-and-Release-Forms

IS YOUR CHILD SICK?®

Visual Symptom Checker

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Pediatrics in Brevard is a NCQA Medical Home