click here
Walk-Ins Are Welcome
Same Day Appointments
954-983-9191

Patient Information Sheet

Sex

Name and number of 2 persons to contact in case of emergency

Do you have a living will?
Health care surrogate?

FINANCIAL POLICY, RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS. Payment for services is due at the time
services are rendered, unless payment arrangements have been approved. We accept credit cards and checks. We will
be happy to assist you in processing your insurance claim. Insurance coverage is a contract between you and your
insurance company and you are ultimately responsible for payment of your bill. I understand that I am financially
responsible for all charges whether or not paid by insurance. I understand that I may be billed for any out of pocket or
reasonable collection fees if my account is not paid in a timely fashion. I hereby authorize and direct my insurance
company to make payment to my physicians, provider and/or associates for services rendered, and I am financially
responsible for non-covered services. I also authorize the provider to release any information required to process my
claim. I photocopy of this assignment shall be considered as effective and valid as the original.



What makes us Different?

Same day appointments available
Walk-ins are welcomed
Or Call 954-983-9191

Get in touch with us.

Services

  • Asthma Treatments
  • Minor Surgery
  • Immunizations
  • Gynecology
  • Labs
  • Electrocardiograms
  • Pap Smears
  • Fitness Testing
  • Allergy Testing
  • Pulmonary Testing
  • Wound Care
  • Pacemaker Services
  • Dental Services
  • X-Rays
  • Free Transportation
  • Pregnancy Testing
  • Glucose Testing
  • Immigration Services
  • Optometry Services
  • Diagnostics
  • Podiatry
  • Hearing Services