Patient Forms

Patient Forms:

New Patient Registration Forms


Physiatric Pain & Medical Rehabilitation Clinic Is Currently Welcoming New Patients

Appointment Information

Appointments are scheduled at the earliest convenience. In the event an appointment needs to be canceled, we appreciate 24 hours’ notice to provide the opportunity for another patient in need of care to be seen.

What to Bring to Your Appointment

  • Medical/Automobile  insurance card
  • Claim number, address, adjusters name, and phone number
  • Valid Form of Id, Drivers License, Passport, or Military Id Card
  • Physician referral forms, if required by insurance
  • List of prescriptions and/or over-the-counter medication, including dose and frequency
  • Information about your medical and surgical history
  • Recent x-rays/MRI  report or relevant records

Patient Forms

For the convenience of our patients, we have the following forms available online in pdf format. Please print out the appropriate forms, complete them, and bring them to your appointment.

Billing Information

To reach our Billing Coordinator, please call 407.291.3077 or e-mail [email protected]

Our Billing Coordinator is available Monday- Thursday from 9:00 am to 5:00 pm. Friday 9:00-12:00pm

Hospital Affiliations

Florida Hospital Healthcare Systems (FHHS) and Orlando Regional Medical Center (ORMC)

Languages Spoken

We speak English and Spanish | Se Habla Español

Privacy Practices

This Notice of Privacy Practices describes how medical information about you may be used and disclosed and how you can get access to this information. Please review its carefully.

Request Appointment
(407) 291-3077

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Orlando, FL



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