352-873-4458

We Listen. We Are Concerned. And We Care.

Because of these things we believe we provide the best in quality healthcare

We Listen.
We Are Concerned.
And We Care.

Because of these things we believe we provide the best in quality healthcare

Forms for Patients

Here at Countryside Medical we care about relationships with all our patients. We make it a point to inform them of the overall medical and financial process that relates to them. Here are the forms and documents that we need. In order to facilitate patient care, please download, print, fill out and return form on your next visit.
New Patient Information
This document collects the patients name and contact information.
Consent To Treat
Patients consent to have Countryside Medical provide whatever treatment deemed necessary to their patients.
Authorization for Disclosure of Protected Health Information
This form will give our office permission to use and/or disclose health information about you to aide or continue treatment of your healthcare
Financial Policy
This form will advise you about the Insurance and our Financial Policy requirements.
Patient History
This form collects all the medical history, social history and family history about our patients
Patient Consent for Use & Disclosure of Protected Health Information
Countryside Medical may use and disclose protected health information about our patients in order to carry out medical treatment and payment
Health Maintenance Information
Patients will list all their medical information to help better inform Countryside Medical.
Advanced Directives
Florida Status requires that we provide our patients with information concerning their rights to a LIVING WILL and/or advance directive.