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Patient Forms

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Health History Form 2025

For NEW PATIENTS, also complete and bring this form with you to your first visit

New Patients Forms 2025

The place is very clean. The staff is professional and friendly. While being examined, everything was explained in detail and answered all my questions.

— Donald S.

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<form-template><fields><field required="true" type="text" name="first-name" placeholder="First Name*" label="First Name"/><field required="true" type="text" name="last-name" placeholder="Last Name*" label="Last Name"/><field required="true" type="text" name="phone-number" placeholder="Phone Number*" label="Phone Number"/><field required="true" type="text" name="email-address" placeholder="Email Address*" label="Email Address"/><field required="true" type="select" name="select-location" label="Select Location"><option value="">Select Location*</option><option value="Altamonte Springs">Altamonte Springs</option><option value="Apopka">Apopka</option><option value="Celebration">Celebration</option><option value="Clermont">Clermont</option><option value="Davenport">Davenport</option><option value="Dr. Phillips">Dr. Phillips</option><option value="East Orlando">East Orlando</option><option value="Hunters Creek">Hunters Creek</option><option value="Kissimmee">Kissimmee</option><option value="Mount Dora">Mount Dora</option><option value="Ocoee">Ocoee</option><option value="Poinciana">Poinciana</option><option value="St. Cloud">St. Cloud</option><option value="No Preference/Not Sure">No Preference/Not Sure</option></field><field type="select" name="area-of-interest" label="Select Area of Interest"><option selected="true" value="">Select Area of Interest</option><option value="Clinical Dermatology">Clinical Dermatology</option><option value="Cosmetic Dermatology">Cosmetic Dermatology</option></field><field type="select" name="existingpatient" label="Existing Patient?"><option selected="true" value="Established Patient">Established Patient</option><option value="New Patient">New Patient</option></field><field type="date" name="date" label="Appointment Date"/><field required="true" type="select" name="appointment-time" label="Appointment Time"><option selected="true" value="8:00-8:30">8:00-8:30</option><option value="8:30-9:00">8:30-9:00</option><option value="9:00-9:30">9:00-9:30</option><option value="9:30-10:00">9:30-10:00</option><option value="10:00-10:30">10:00-10:30</option><option value="10:30-11:00">10:30-11:00</option><option value="11:00-11:30">11:00-11:30</option><option value="11:30-12:00">11:30-12:00</option><option value="1:00-1:30">1:00-1:30</option><option value="1:30-2:00">1:30-2:00</option><option value="2:00-2:30">2:00-2:30</option><option value="2:30-3:00">2:30-3:00</option><option value="3:00-3:30">3:00-3:30</option><option value="3:30-4:00">3:30-4:00</option><option value="4:00-4:30">4:00-4:30</option><option value="4:30-5:00">4:30-5:00</option></field><field type="text" name="insurance2" placeholder="What is your Health Insurance?"/><field required="true" type="select" name="preferred-call-time" label="When is a good time to call?"><option selected="true" value="">When is a good time to call?*</option><option value="Morning">Morning</option><option value="Afternoon">Afternoon</option><option value="Evening">Evening</option></field><field type="textarea" name="comments" placeholder="Enter any comments or questions here..." label="Comments"/><field type="hidden" name="rendered-form" value="is_rendered"/></fields></form-template>

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