Thank you for taking time from your busy schedule to download our New Patient Forms. If you have any questions about these forms, feel free to call our office at (904) 997-7776 during working hours.

Patient appointments are not scheduled until all COMPLETED forms are received by the office, along with a LEGIBLE copy of the responsible party’s Driver’s License (or other VALID form of Government Issued Identification) and a copy of the insurance card.

      Child New Patient                                                                                                        

1) Patient Registration Form                                                                                      

2) New Patient Form-Child                                                                                     

3) Office Policies                                                                                                          

4) Release Authorization Form (to request a release of medical records)                   

5) Crisis Management for Self Pay Patients (if applicable)                                      

6) Credit Card Authorization

     Adult New Patient

 1) Patient Registration Form

2) Office Policies

3) Release Authorization Form (to request a release of medical records)

4) Crisis Management for Self Pay Patients (if applicable)

5) Credit Card Authorization

 

FORMS MAY BE SUBMITTED VIA:

• Fax (904) 997-7057
• Mail 7545 Centurion Pkwy, #302 Jacksonville, FL 32256
• Calling the office (904) 997-7776 for the encrypted email address
• In person Tuesday-Friday during office hours

NOTE:

These forms MUST be completely filled out and returned to the office for review prior to your first appointment with Dr. Farinas being scheduled.

Being able to review the information you provide, before your first appointment with me, will maximize our time together.

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• Patient Registration Form

 

• New Patient Form - Child

       (filled out by a parent or a guardian) 
 

• Notice of Privacy Practice

 

• Office Policies

• Crisis Management Policy 

 

• Release Authorization Form 

       (to request a release of medical records)
 

• Legal Policies

• Mental Health Advance Directive

•  Credit Card Authorization

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All forms are provided in Adobe PDF format. 

Instructions to download forms:
1.  Click on the form name 
     (form will open in new window)
 
2.  Print your forms once Adobe Reader opens the file.

Adobe Acrobat Reader is required in order to view and print the forms. 
If you don't have Adobe Acrobat Reader installed on your computer, click the link bellow to download free Acrobat Reader.