Please complete each document prior to your visit to Dr. Petrites. Note: You will need Microsoft Word to review and print the documents. NEW PATIENTS Patient Demographics Insurance Information Financial Policy Medical History Acknowledgment of privacy policy ESTABLISHED PATIENT FORMS Patient Demographics (complete only if this has changed from your last visit) Established Medical History Release of medical records (optional) PRIVATE POLICY Privacy Policy Office Policies When a patient is referred to Dr. Petrites for care, the first step is the office visit. Appointments are scheduled as promptly as possible. At the time of your visit we ask you to bring your insurance cards and to fill out information forms; this is necessary for us to provide you with optimum medical care. If surgery is necessary, it will be scheduled after your office visit and we will notify you of all details. Scheduling a surgery involves the merging of several different schedules. Please let us know at the time of your office visit if you have any date restrictions. Your post-operative course may involve several follow-up visits. Instructions are always provided and if you have any questions or problems, just call our office for help. As a surgical practice, our schedule can be disrupted by emergencies. If this happens, we ask for your patience and understanding as we reschedule your appointment or ask you to “wait by the phone” for us to call you in later that day.

Bonita Community Health Center   3501 Health Center Blvd, Suite 2110   Bonita Springs, FL  34135