For new patients or to update your file:
Please fill out this form and then go to the Appointments section to request an appointment.

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New Patient           Current Patient   Please update my current information

First Name: * MI:   Last Name: *

Address: *

Suite/Apt #

City: *   State:    Zip Code: *  

Birthday:  January February February March April May June July August September October November December / / *                  SSN: *

Contact Number:  *

Cell  Phone Number:  

Work Number: 

E-Mail Address: *

Marital Status: select... Minor Single Married Divorced Separated Widowed

Spouse's Name:

Do you have children? Yes No How many?

Referred by:

Employer:

Occupation:

Preferred Pharmacy:  Please choose for faxed RX Albertsons DM 932-5361 Albertsons Ehrlich 908-7188 Carrollwood Pharmacy 961-8798 CVS 24h Dale Mabry 969-4283 CVS Bearss 908-0889 Eckerds Carrollwood 961-8772 Eckerds Citrus Park 926-6903 Eckerds Ehrlich 968-4003 Eckerds Gunn 963-5355 Eckerds Lambright 873-0472 Eckerds Northdale 264-6803 Eckerds W Waters 884-2518 Eckerds Westchase 926-3756 Kash n Karry Citrus Park 920-6306 Kash n Karry Ehrlich 969-1638 Kash n Karry Westchase 792-8910 K-Mart Carrollwood 961-6165 Publix Anderson 960-4403 Publix Citrus Park 926-5256 Publix Van Dyke 264-5993 Publix 15151 N Dale Mabry 265-3392 Target Northdale 962-6133 Target Waters 885-1792 Walgreens Citrus Park 920-9535 Walgreens Fletcher/DM 962-4983 Walgreens Gunn 969-4203 Walgreens 24h Hill/Memorial 885-2766 Walgreens 24h Northdale 264-7722 Walgreens Sheldon 884-1487 Walgreens W Waters 887-3166 Wal-Mart Dale Mabry 265-8870 Wal-Mart Waters 881-0802

***For your convenience your prescriptions can be faxed if you provide us with the pharmacy.***

Describe the reason for your visit:

What medications do you take: (List medications, dose, frequency)

Do you now have or have you ever had any of the following:

List Past Medical History, Surgery, Hospitalizations:

Contact:

Relationship to you:

Home phone # Work phone #:

Person ultimately responsible for your account:  To expedite your visit please send us your updated insurance information so that we can pre-certify your visit.

Same as above:  

First Name:  MI:   Last Name:   Sex:  M F

Address:        City:    State: 

Birthday:  January February February March April May June July August September October November December / /

Health Insurance Name: Please choose Aetna Blue Cross/Shield PPO Health Options Humana Other Self-pay United * Other Insurance:

Insurance ID #: *   Group #:    SSN: *

Relationship to you: *  

Insurance Billing address:

PO Box: *

City: *   State:    Zip Code: *  

Phone Number:    

If a required field does not apply to you put none.

I understand that all charges (including those not paid by insurance), collection fee, bank/returned check fees, legal fees and failure to keep appointment fees are the financial responsibility of the patient (or the parent/guardian in the case of a minor). I hereby authorize Dr. Schweinshaupt to release all information concerning my illness (es) and treatments to my insurance carriers/health plans. In the event that Dr. Schweinshaupt participates with my insurance carrier/health plan, I hereby assign all available benefits and payments directly to him for medical services rendered. I understand that I am financially responsible for all balances not covered by my insurance carrier/health plan, and authorize Dr. Schweinshaupt to charge my credit card for the full amount of any unpaid balances.  I acknowledge notification of the privacy practice act.

* denotes required field