We Listen. We Are Concerned. And We Care.

We Listen.
We Are Concerned.
And We Care.

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

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

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.

Financial Policy

This form will advise you about the Insurance and our Financial Policy requirements.

Health Maintenance Information

Patients will list all their medical information to help better inform Countryside Medical.

Consent To Treat

Patients consent to have Countryside Medical provide whatever treatment deemed necessary to their patients.

Patient History

This form collects all the medical history, social history and family history about our patients.

Advanced Directives

Florida Status requires that we provide our patients with information concerning their rights to a LIVING WILL and/or advance directive.

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.

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.

New Patient Information

This document collects the patients name and contact information.

Financial Policy

This form will advise you about the Insurance and our Financial Policy requirements.

Health Maintenance Information

Patients will list all their medical information to help better inform Countryside Medical.

Consent To Treat

Patients consent to have Countryside Medical provide whatever treatment deemed necessary to their patients.

Patient History

This form collects all the medical history, social history and family history about our patients.

Advanced Directives

Florida Status requires that we provide our patients with information concerning their rights to a LIVING WILL and/or advance directive.

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.

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.