This form contains a representative list of potential fees and charges you may incur, so you are better informed at the time of service, and prior to the arrival of a billing statement.

New patients must review and acknowledge receipt of this information prior to your first visit.

A summary of patient's rights and responsibilities, per Florida Statute 381.026

As of 2023, this statement will be presented to all patients as part of registration. It is our PHCA philosophy regarding the unique challenges and sensitive nature of medical care for children of divorced or separated parents. This is designed to help parents navigate these sensitive areas and avoid misunderstandings during the treatment process. 

Parents - please complete this screening if you will be receiving flu or pertussis vaccine from your child's pediatrician. 

For parents-to-be who would like a prenatal meeting before baby arrives, please complete this short questionnaire to help us get to know you.

If your child is scheduled for a vaccine-only visit for any immunization, please bring this completed form to the visit.

If your child is age 2 years or older, he or she may be eligible to receive the intranasal flu vaccine, FluMist. If you would like your child to receive this type of flu vaccine, please complete this form for review with your pediatrician.

Please complete this form to authorize the Alliance to administer the influenza vaccine to your child. Prior to signing this form, you will need to read the Vaccine Information Statement from the Centers for Disease Control and Prevention.

This form provides parent consent for the adolescent questionnaire that is discussed at well visits for ages 17 years and younger.

This form is completed with parent consent at adolescent well visits for ages 17 years of age and younger.

This form is completed at well visits for ages 18 years of age and older.

This sports form is to be completed by the parent and will accompany the ECG test with results.

This sports form is used in the event the student needs to be referred to a specialist prior to sports participation.

This sports form is completed by the doctor or advanced practitioner performing the physical exam.

This sports form is for the parent and student to complete and sign.

Complete these forms only if your pediatrician requests them for a follow up visit.

Complete estos formularios solo si su pediatra los solicita para una visita de seguimiento.

Complete these forms only if your pediatrician requests them for a follow up visit.

Parents should print and complete this form prior to your child's appointment for evaluation of ADD/ADHD. Please bring both completed forms to your appointment.

Los padres deben imprimir y completar este formulario antes de la cita de su hijo para la evaluación de TDAH. Por favor, traiga ambos formularios completos a la cita.

Complete these forms only if your pediatrician requests them for a follow up visit. 

Complete estos formularios solo si su pediatra los solicita para una visita de seguimiento.

Parents should print and have your child's teacher complete this form prior to your child's appointment for evaluation of ADHD. Please bring both completed forms to your appointment.

Los padres deben imprimir y pedir al maestro de su hijo que complete este formulario antes de la cita para la evaluación del TDAH. Por favor, traiga ambos formularios completos a la cita.

This form will be provided to you at the time of prescription refill for ADD - ADHD medication(s). This states our policy regarding follow up and monitoring of your child's status, based on medical industry and health insurance quality care standards.

This diary is to help keep track of your meals, water, physical activity, and screen time to help everyone follow the guidelines for a healthy family. Please use this diary each week, and bring completed diaries to your child's weight management visit.

After your child's initial Weight Management visit, a follow-up visit will be scheduled. Please bring this completed questionnaire with you.

If your pediatrician schedules a Weight Management visit, please bring this completed questionnaire with you.

This form is used to assess your child's level of asthma. Please complete it before your next appointment and ask the office staff to place it in your child's chart. The pediatrician or nurse practitioner will review the questionnaire with you.

Patients will need to complete this CDC screening checklist prior to receiving the COVID-19 Vaccine.
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V-safe is a smartphone-based tool that uses text messaging and web surveys to provide personalized health check-ins after you receive a COVID-19 vaccination.
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General information about the Vaccine Adverse Event Reporting Sytem
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Please note:  Motrin is not recommended for infants less than 6-months of age.