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407-905-8827

Orange County

352-314-7400

Lake County

Patient Intake Form

This form is for new patients or patients that have not been seen by a provider in more than two years and is expected to take ten minutes to complete. You will need to complete our Patient Intake Form before your first appointment.

After completion of this form, if you’ve not already requested an appointment, please call us at 407-905-8827 or use the online appointment request form.

To protect your privacy, please refrain from providing personal health information or any other sensitive information via contact form. A patient service rep will contact you and request the needed information.

Orange County

Lake County

Our mission is to provide quality and compassionate primary healthcare services to Central Florida’s diverse communities.