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Cocoa Beach (321) 784 5437

Melbourne (321) 724 5437

Rockledge (321) 636 3066

Viera (321) 435 9800

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

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Same Day Sick Appointments
Morning Walk-In Sick Clinic
Weekend Hours
Free Newborn Care Class
Patient Portal

Patient Portal
Holiday Safety by Dr. Ulrich

The holidays are filled with traditions, but we must also remain safe so the lasting memories are fulfilling and memorable.

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January is National Birth Defects Prevention Month!

Certified Pediatric Nurse Practitioner Lea Dickens shares healthy behaviors to adopt to increase the chances of having a healthy baby.

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