Monday - Friday8:00am-5:00pmSaturdays9:00AM-3:00PMCall us+1 850.231.1919Fax+1 850.231.1918

Forms


Patient Form

We ask that all patients complete this form online prior to check in. This will allow for a touch-free check-in process.

Please email your identification and insurance documents directly to info@docsmiley30a.com.

If you are completing this form for COVID testing we do NOT need your Driver’s License and Insurance as COVID testing is a cash-only service.


Telephone

Date of Birth

Address

Medications

Allergies

If you are a new patient or your insurance has changed, please email a photo of your Driver’s License and the front/back of your insurance card to info@docsmiley30a.com


Consent
By checking this box, I consent to treatment by Doc Smiley's Urgent Care.
Email Consent
By checking this box, I consent to receive lab results by email.
HIPAA Privacy Disclosure
By checking this box, I acknowledge the privacy policies (HIPAA). If you would like a copy you may request one.






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Call Us


+1 850.231.1919

If you have a medical emergency
please dial 911.

Fax: +1 850.231.1918