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

Forms & Policies

New Patients

Registration Forms for New Patients (PDF)

Adult Patients

Registration Forms for Patients 18 years and older (PDF)

Patient Forms and Office Policies

Patient Information Form (PDF)
Financial Policy (PDF)
Vaccine Policy (PDF)
Consent for Treatment (PDF)
Medical Release Form (PDF)
Consent-to-Release-PHI (PDF)
HIPAA Form (PDF)
Privacy Policy (PDF)
Notice Informing Individuals about Nondiscrimination (PDF)
Grievance Procedure Policy (PDF)

ADHD Forms

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

Anxiety Forms

SCARED-Child
SCARED-Parent

Depression Forms

KADS-6

Sports Participation Forms

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

IS YOUR CHILD SICK?®

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Pediatrics in Brevard is a NCQA Medical Home