Patient Intake Form
Form for Dr. Paul Meli and Dr. Jack Trainor
This Form can be completed now to save you time when you visit our Office for the first time.
Completing this form does not schedule or confirm an Appointment with our Doctors. First, call our office at 954-771-8177, and speak with one of our friendly staff members to schedule or to confirm an Appointment. Then you can complete this Form.
Completing this Form now can reduce the necessary paperwork to be completed for your first Appointment. We hope it helps to be able to complete this Form now, at your convenience, in the comfort of your home.
Please be sure to enter your name on this form EXACTLY as it reads on our Insurance Card or Medicare Card.
About this Form
ALL information provided to our office through the privacy of our Web Site is confidential.
Be sure to specify the following:
- The Doctor you are scheduled to see
- The date and time of your scheduled Appointment.
- The SINGLE Primary problem or need that you have for this Appointment
- Your Insurance or planned method of payment
- REMEMBER, if your Insurance Company is an HMO you will need a Referral from your Primary Care Physician (PCP) to see a Doctor. Our Business Office must have your Referral, in hand, at the time of your Appointment to see a Doctor.
Referrals
Please be sure that your Primary Care Physician (PCP) understands why you are seeing a Specialist. Be sure they provide a correct DIAGNOSIS CODE and authorize DIAGNOSTIC TESTING, along with your CONSULTATION/OFFICE VISIT on the Referral.
For added convenience referrals can be FAXED to our office at any time, by you or your PCP, at 954-771-3629.
Insurance Questions and Planned Method of Payment
Be sure to discuss your Insurance Coverage and planned method of payment with our office staff when you schedule your Appointment. This saves time and eliminates any confusion when you arrive for your first appointment.
We accept many Insurance Plans. But, BE SURE TO ASK about yours when you schedule your Appointment.
Bring your Insurance Card and Identification with you to your first appointment.