Monday - Friday
8:00 - 5:00
407-679-4800
Health Care for the
Whole Family!
Jane-Marie Raley, DO
Ronald Burns, DO
Kathleen Davis, APRN
Sarah Norman, APRN
Forms and Documents
Welcome to our office: A Letter To Our Patients
Please print and complete the information form, medical history form and HIPPA form at your earliest convenience, and then bring them 20 minutes before your appointment.
We require your driver's license/ ID and insurance card.
Insurance questions? We have some info here, or you can email us if you have further questions. We're excited to help you!
New Patient Information Form
This is a mandatory sheet and must be filled out completely. Please include all contact information so we can communicate most effectively. We do use e-mail and text.
HIPAA Form
Health Insurance Portability and Accountability Act of 1996 requires patient consent for use and disclosure of protected health information. This is a law to safeguard your personal information.
Medical Release
This form is for the patient if they ever need to access their records or want them to be sent to another medical facility for any reason. If this form is being used for the purpose of transferring forms to a specialist, please make sure to fill out the address, phone number and fax number.
Adult Medical History
This history allows us to understand your current and prior health conditions. It helps us identify any future health problems that may come from your family history.
Pediatric Form
These forms are for the patients under the legal age of 18, and must be signed by their guardian in order for them to be seen as a patient. We collect their medical history, as well as their general information.
Advanced Care Directive
What is an Advanced Care Plan? Advance care planning (ACP) is the face-to-face time a physician or other qualified health care professional spends with a patient, family member, or surrogate to explain and discuss advance directives.