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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

IS YOUR CHILD SICK?^®

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Warm weather dwellers not immune to flu

Dr. Cheney reminds us to get our annual influenza vaccines.

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Breast cancer affects all, even the young.

Dr. Imami, of TEPAS Breast Center in Melbourne, and Dr. Ulrich, of Pediatrics in Brevard discuss breast cancer in young patients. Read the Florida Today article.

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

Patient Portal