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Pediatrics in Brevard, Cocoa Beach, Melbourne, Rockledge, Viera, FL
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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
Patient Portal
Pay My Bill

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About Us

WelcomeTestimonialsProvidersKids ClubPractice NewsPatient Centered Medical Home

Contact Us

Locations & HoursPatient SurveyPatient PortalCareers & Opportunities

Resources

ImmunizationsMedical LibraryFormsParent ResourcesPediatric Advisor Resources

Office Info

AppointmentsEmergenciesMorning Walk-In Sick ClinicWeekend HoursAfter HoursSick VisitsWell VisitsInsurance

Pediatrics in Brevard is a NCQA Medical Home
  • Same Day Sick Appointments

     
  • Morning Walk-In Sick Clinic

     
  • Weekend Hours

     
  • Free Newborn Care Class

     
  • Patient Portal

    Patient Portal
     
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