Contact Information

Appointments and General Inquiries
(727) 822-5393

Billing
(727) 822-5393

Fax
(727) 895-3313

Email

ellispeds103@yahoo.com

Poison Control
(800) 222-1222

 

Forms 

Our office requires patients to vaccinate and follow a vaccine schedule.

New Patients, please read #1, the Office Policy and keep a copy for your records.  Print out forms 2 – 7, fill them out at your convenience and bring them to your first office visit. You will need to fill out a New Patient Health Questionnaire  (#2) for each child.   You may also fax the forms to 727-895-3313.  Print and fill out #8, the Records Transfer Request if you need to request records from your previous pediatrician. 
 
All new patients must provide the most recent immunization record.

If you have scheduled an ADHD consultation, print out #9 and #10.  Each parent and teacher can fill out a form.  Please bring these to your appointment along with a current report card.

If you have an appointment scheduled for 18 month or 24 month checkup, please print and fill out #11 and bring to your appointment.

 

  1. Office Policy
  2. New Patient Health Questionnaire
  3. Patient Information
  4. HIPAA Privacy Practices
  5. Government Required Information
  6. Insurance Assignment
  7. Implied Consent
  8. Records Transfer Request
  9. ADHD Assessment Scale – Parent
  10. ADHD Assessment Scale – Teacher
  11. M-CHAT Modified Checklist for Autism in Toddlers