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Online Forms

/Online Forms
Online Forms2016-06-19T17:41:40+00:00

Advanced Physical Medicine offers our patient form(s) online so they can be completed it in the convenience of your own home or office.

If you do not already have AdobeReader® installed on your computer, Click Here to download.
Download the necessary form(s), print it out and fill in the required information.
Fax us your printed and completed form(s) or bring it with you to your appointment.

New Patient Health History Form – Required

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

Download & Print Form

Member Wellness Registration Form – Optional

This form can be filled out to register for access to the member wellness section of our website. You can also sign up for our monthly newsletter to keep up on current health issues and news and events in our office. You can print it out and bring it in to our office or Click Here to register online! The online newsletter sign-up is also on the right. We look forward to making your experience with our office and website more interactive and rewarding!

Download & Print Form

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PRIVACY STATEMENT

We are committed to protecting your privacy. Authorized employees within Advanced Physical Medicine on a need to know basis only use any information collected from individual customers.

We constantly review our systems and data to ensure the best possible service to our customers.

We will investigate any such actions with a view to prosecuting and/or taking civil proceedings to recover damages against those responsible

Terms and Conditions

In using this website you are deemed to have read and agreed to the following terms and conditions:

The following terminology applies to these Terms and Conditions, Privacy Statement and Disclaimer Notice and any or all Agreements: “Client”, “You” and “Your” refers to you, the person accessing this website and accepting the Company’s terms and conditions. “The Company”, “Ourselves”, “We” and “Us”, refers to Advance Physical Medicine “Party”, “Parties”, or “Us”, refers to both the Client and ourselves, or either the Client or ourselves.

All terms refer to the offer, acceptance and consideration of payment necessary to undertake the process of our assistance to the Client in the most appropriate manner, whether by formal meetings of a fixed duration, or any other means, for the express purpose of meeting the Client’s needs in respect of provision of the Company’s stated services/products, in accordance with and subject to, prevailing Florida Law.

Any use of the above terminology or other words in the singular, plural, capitalisation and/or he/she or they, are taken as interchangeable and therefore as referring to same.

Confidentiality

Client records are regarded as confidential and therefore will not be divulged to any third party, other if legally required to do so to the appropriate authorities. Clients have the right to request sight of, and copies of any and all Client Records we keep, on the proviso that we are given reasonable notice of such a request. Clients are requested to retain copies of any literature issued in relation to the provision of our services. Where appropriate, we shall issue Clients with appropriate written information, handouts or copies of records as part of an agreed contract, for the benefit of both parties.

We will not sell, share, or rent your personal information to any third party or use your e-mail address for unsolicited mail. Any emails sent by Advanced Physical Medicine will only be in connection with the provision of agreed services and products.