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

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: *

Home Phone 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.

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

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: *     Co-pay amount: 

Insurance Billing address:

PO Box: *

City: *   State:    Zip Code: *  

Phone Number:                          

Payment method: Cash Check Credit Card

Credit Card Type: Visa Mastercard Other

Credit Card Number:

Exp. date:

We invite you to discuss with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider and patient.

I understand that all charges are the responsibility of the patient.  If your account has not been paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, and any other expenses incurred in collecting your account.  I understand that I am responsible for any amount not covered by my insurance plan.

By submitting this form you authorize Dr. Schweinshaupt to release any information to your insurance company required to process your insurance claims.

By submitting this form you guarantee that it was completed correctly to the best of your knowledge and that you understand that it is your responsibility to inform this office of any changes to the information you have provided.

* denotes required field