For Patients

New Patient Registration Forms

In order to expedite the new patient registration process, we kindly ask you to download and E-mail or print out all of the required new patient registration forms and bring these forms with you to your first appointment.

• New Patient Registration Form


• New Patient Medical History Form FOR ALL CENTRAL FLORIDA/DAYTONA BEACH PATIENTS


• New Patient Medical History Form FOR ALL JACKSONVILLE AND GEORGIA PATIENTS


• Medication List


• Insurance Authorization Form


• HiPAA Patient Signature Form


• Medical Release Form

You can now complete these forms on your computer. Once you have completed them, please click here and send the completed forms by E-mail to us. We will gather your signature at time of check-in.

Here are some instructions on how to download and E-mail the forms to us:

Step 1. Please click the individual form link and download each form.
Step 2. Open the form in Adobe Acrobat Reader. Click here to install the Acrobat Reader, if you should not already have it on your computer.
Step 3. Kindly fill in the requested information and save the form on your computer.
Step 4. Once you have completed all forms, kindly send the forms via E-mail attachment to contact@floridaretinainstitute.com.

In addition to completing the forms, we ask that you please read the following document containing information on the Florida Retina Institute privacy practices. This document is for your personal information and you do not have to bring it to your appointment.

Florida Retina Institute - HiPAA Privacy Policy

By providing us with the signed Patient Signature Form you acknowledge, with your signature, that you have read and fully understand the Florida Retina Institute privacy policies, as explained in the Privacy Policy document.