Forms

THEODORE YAREMO, M.D.,PA

If you are a new patient, we will be happy to email a copy of the New Patient forms to you prior to your appointment. Please print and complete the New Patient Registration packet prior to reporting for your appointment to expedite your registration on the day of your appointment.

 

Please bring the following items with you to your appointment:

 

  • All current insurance cards (a must at every appointment)
  • Photo ID (driver license or passport)
  • A completed list of your medications including name, dosage, how many times a day you take it and who prescribed it.
  • A list of vitamins, herbs, supplements, and over the counter medication(s) currently being taken
  • Authorization from your Insurance Company if you are HMO insured. Your Primary Doctor (PCP) can obtain this for you to see us.
  • Your calendar of availability in case you and your doctor decide a procedure will be necessary to schedule at the time of your appointment
  • As established by your insurance company, a co-payment, co-insurance and or deductible are due at the time of check-in. We accept Cash, Visa and MasterCard.

 

If you find it necessary to reschedule or cancel your appointment due to unexpected circumstances, we ask that you please be considerate of our provider's time and call 24 hour in advance to allow other patients to be seen at your assigned appointment time. Failure to do so could result in a no show fee of $50 dollars.

 

If you have any questions, please don't hesitate to call us at 941-637-6062. Again, WELCOME and we look forward to providing quality healthcare to you.

 

  • New Patient Checklist

 

  • New Patient Registration Packet

 

  • Adult Health History Form

 

  • Office and Financial Policy Form

 

  • Cardiac Screening Form

 

  • Medical Records release Form

 

  • Patient Rights Form

 

  • Communication HIPAA Form

 

  • EGD Instruction Form

 

  • Colonoscopy Instruction with Clear liquid diet Form

2310 Tamiami Trail, Suite 2101

Punta Gorda, FL 33950

Publix Plaza corner of Airport Rd and US41

located in the Walk in Medical Care

 

(941) 637-6062

(941) 575-4449

 

THEODORE YAREMO, M.D., P.A.

 

Since 1988, our practice has been serving the needs of patients and referring physicians.

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