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)
Financial Policy for Patients Over 18 Years
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?®

Visual Symptom Checker

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Resources

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Office Info

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Pediatrics in Brevard is a NCQA Medical Home

  • Free Newborn Care Classes

    Contact 321.636.3066 x 410 to attend our next Newborn Care Class.

     

  • PIB Announcement

    Pediatrics in Brevard (PIB) recently partnered with Privia Medical Group (PMG)-Florida, a multi-specialty physician led group. While we look forward to the benefits of this partnership, we want to be clear, Pediatrics in Brevard remains an independent physician owned pediatric practice and continues to make all the decisions affecting our patients’ care. Click here to read our full announcement. 
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