New Patient Forms
Warning: A doctor-patient relationship is not establish by submitting forms.
We can only consider you as a patient after the first appointment.
Please note: We at RDV follow the American Academy of Pediatrics standards
regarding vaccinations and do not accept patients that do not vaccinate.
We do understand some parents would like to limit the number of vaccines given during one appointment, and we could arrange for an alternative schedule, but most insurances will not cover the extra appointment needed. Please let your provider know about your intentions and she will explain how we can accomplish this with no major consequences.
Option 1 (Online Version):
Fill out and submit the forms via the the "Secure Online Forms" version link below and we will receive your information via our secure server.
Fill out and submit the forms via the the "Secure Online Forms" version link below and we will receive your information via our secure server.
Online Electronic Forms (English):
Online Electronic Forms (Spanish):
Option 2 (Fill Out by Hand & Submit Via Email/Fax/In-person):
1. Fill out the PDF form below by typing in the PDF file directly or printing and filling it out by hand.
2. Submit your New Patient Paperwork to us via any of the following:
1. Fill out the PDF form below by typing in the PDF file directly or printing and filling it out by hand.
2. Submit your New Patient Paperwork to us via any of the following:
- Email at [email protected]*
- Fax to 407-916-4525
- Bring a hard copy to your first appointment (be sure to arrive at least 15 mins early)
New Patient Forms:
| new_pt_forms.pdf |
Submit a photo of your insurance card!
(This form works best with a mobile phone camera)
(This form works best with a mobile phone camera)
