Phone: (954) 531-0847

Fax: (954) 531-0915

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New Patient Form

NEW PATIENT INSTRUCTIONS FOR FILLING OUT ONLINE FORM

Welcome to Developmental & Behavioral Pediatrics of South Florida. To make your first visit to our office more smooth and efficient, we ask that you give us a little more information about your child and complete the new patient form below before your scheduled appointment. Please fill out all fields to the best of your knowledge to make this process go quickly for you and supply us with the information we need to best help your child. If there is a field that you do not have the information for please enter “N/A” in the form field. The more information you provide us the better we can provide your child with an effective treatment. Thank you, we look forward to seeing you and your child for their first appointment.

Please fill out the form below before making an appointment, so that we may serve you better
Name of Person Completing This Form:
Name of Person Who Referred You To Our Office:

Patients Information
Patient's Full Name:
Patient's Date of Birth: mm/dd/yyyy
Pediatrician/Primary Care Physician:
Primary Care Physicians Phone Number:
Name of Daycare/School/Work:
Patient's Grade in School:
Health Insurance Provider:
If Divorced, Who Has Custody?: MotherFatherNot Applicable
Your Child’s Adoption Status:

Patient's Health
Prior Diagnosis:
Current Diagnosis:
Immunizations Up To Date?: YesNo
Current Treatments or Therapies:
Current Medications and Dosages:
Current Supplements and Vitamins:
Please List Any known Medication allergies:
What Specialists Have You or Your Child Seen Previously?:
Why Are You Seeking Help Now?:
Are There Immediate Critical Concerns Such as Suicide Attempts, Extremely Violent or Aggressive Behavior, and Any Unusual Behaviors?:
Have You or Your Child Ever Had a Head Injury? If So, Please Provide Details:
Please Check All of The Current Concerns For You or Your Child:
Learning Problems Behavior in school Sad Negative
Academic potential/intelligence Speech and Language Overactive Bullies others
Physical agility, motor skills Adaptability Sets fires Destroys property
Sensitivities to environment Family Relationships Sexually inappropriate Sexually promiscuous
Getting along with peers Social relationships; has no friends Lies Steals
Weird thoughts Aggressive outbursts Unable to focus on school work Gang activity
Confused Moody Serious injury to another person Problems with law enforcement
Withdrawn Fearful Unusual behaviors Suspected drug or alcohol abuse
Difficulty understanding school work Oppositional Access to firearms or weapons of any kind Behavior at home Cruelty to animals

Parent One Or Self
Full Name:
Address:
City:
State:
Zip Code:
Cell Phone:
Home Phone:
Work Phone:
Occupation:
Email Address:

Parent Two
Full Name:
Address:
City:
State:
Zip Code:
Cell Phone:
Home Phone:
Work Phone:
Occupation:
Email Address:
Welcome to Developmental and Behavioral Pediatrics of South Florida!

In order to serve you best, please, review our policies and procedures. The documentation we require is vital in providing you with comprehensive and coordinated care. Reading this letter and accompanying documents and completion of the online forms indicate agreement with our office policies.

The online form must be completed at least 48 hours prior to your first office visit. Completion of these forms indicates that you have read, reviewed and are in agreement with our HIPPA compliant privacy practices as stated below:

I have reviewed the Privacy Practices for Judith Aronson-Ramos, M.D. and understand a copy is available in her office and on her Website for me to review at all times. >This is also to acknowledge that I authorize Dr. Aronson-Ramos and staff to:

To communicate with me by email regarding appointments. Other email communications can be conducted at the patient’s discretion. However confidentiality of email communications beyond typical and customary safeguards cannot be guaranteed and email should be used with discretion. Urgent matters or emergencies should never be communicated via email. Additionally email is not a substitute for face to face communication or phone calls when necessary.

To use a secure encrypted online scheduling program to schedule appointments. I understand that I do not reply to automated office reminders.

I also understand that office updates and general information will be posted on the website available for me to review at all times.

A copy of the Privacy Practices for Dr. Aronson-Ramos is available here and in the office.

If I do not agree with any of the above I will communicate this directly with the office staff.

You will be provided with an invoice at the time of your visit, which you can use to file a claim with your insurance company if you choose to do so. However, we cannot guarantee your insurance company will reimburse you. Generally we spend considerably more time with our patients than insurance companies permit. In this fee for service practice you are responsible for payment in full at the time of your visit. If our policies should change and we accept your insurance, you will be notified at your office visit. Dr. Aronson-Ramos is a provider on some insurance plans only through her clinical activities at Joe DiMaggio Children’s Hospital. Though your insurance company may list Dr. Aronson-Ramos as a provider, this is not for services rendered in her private practice.

We also ask that you please notify us of any changes in address, phone numbers, email or medical status during your or your child’s treatment. This is vital to maintaining excellent communication between us. Appointment cancellations require 24 hours notice or you will be financially responsible for the visit. Changes in office policy and procedures will be posted on the website. It is recommended that you check it prior to any scheduled visits for information and/or updates.

If there is a true after hour’s emergency you should always first contact 911. If there is an urgent matter and you feel you need to speak to the doctor immediately you can contact Dr Aronson-Ramos at 561-901-3965. Please note our office is closed on Fridays, non-urgent calls after that time will be answered the next business day. Friday and Saturday appointments are available by special request only.All medication refills, appointments, and non-urgent matters should be addressed during regular business hours Mon-Thurs 8:30-5. We do appreciate 24 hours notice for all refill requests. If your have any questions regarding the above information please let us know.

Welcome to our practice!
Judith Aronson-Ramos, M.D. & Staff
Developmental & Behavioral Pediatrics of South Florida

Updated June 1, 2012
Policy Agreement. - Checking this box means that I have read and understand the policies and procedures as set forth by Dr. Aronson-Ramos and the Developmental & Behavioral Pediatrics of South Florida.
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