Cocoa Beach (321) 784 5437

Melbourne (321) 724 5437

Rockledge (321) 636 3066

Viera (321) 435 9800

Palm Bay (321) 327 8773

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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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Dr. Nguyen
NP Emine Comer

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

Depression Forms

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