East Florida Premium Medical Care is a trusted outpatient primary care practice located in Tamarac,

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About Us
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Patient’s Form
Contact Us

Permission to Share Medical Information

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Permission to Share Medical Information

I freely give my permission for the health care providers at East Florida Premium Medical Care, LLC to discuss any and all issues pertaining to my health with the following individuals (please do not list doctor’s, RELATIVES ONLY)

Name(Required)

This consent is given with full understanding that any information will be given verbally only. Physical copies of medical records must be requested and collected by me. Consent is also given with full understanding that I may change, remove, or add names to the list, or withdraw consent altogether, at any time.

Exception: Please circle may or may not below.

The following issues specific to my health MAY/OR MAY NOT be discussed.

Issues related to Sexually transmitted diseases

Issues related to Pregnancy

Issues related to psychiatric diagnoses

Other issues

Please List

Patient Signature(Required)

Date

MM slash DD slash YYYY

Permiso para Compartir Información Medica

Yo doy libremente mi permiso para que los proveedores de atención médica de East Florida Premium Medical Care, LLC discutan todos y cada uno de los temas relacionados con mi salud con las siguientes personas (por favor, no mencione a los médicos, SOLO FAMILIARES)

Name(Required)

Este consentimiento se otorga con el pleno entendimiento de que cualquier información se dará solo verbalmente. Las copias físicas de los registros médicos deben ser solicitadas y recogidas por mí. El consentimiento también se da con el pleno entendimiento de que puedo cambiar, eliminar o agregar nombres a la lista, o retirar el consentimiento por completo, en cualquier momento.

Excepción: Por favor, marque con un círculo puede o no puede a continuación.

Los siguientes temas específicos de mi salud PUEDEN o NO ser discutidos.

Cuestiones relacionadas con las enfermedades de transmisión sexual

Problemas relacionados con el embarazo

Problemas relacionados con los diagnósticos psiquiátricos

Otros temas

por favor, especifiqué

Su Firma(Required)

Fecha

MM slash DD slash YYYY

Pèmisyon pou Pataje Enfòmasyon Medikal

Mwen bay pèmisyon libreman pou founisè swen sante nan East Florida Premium Medical Care, LLC pou yo diskite nenpòt ak tout pwoblèm ki gen rapò ak sante mwen avèk moun sa yo (tanpri pa mete doktè, selman Fanmi)

Name(Required)

Konsantman sa a bay ak konpreyansyon total ke nenpòt enfòmasyon yo bay pral fè vèbalman sèlman. Kopi fizik nan dosye medikal yo dwe mande epi ranmase pa mwen. Konsantman an tou bay ak konpreyansyon total ke mwen ka chanje, retire oswa ajoute non nan lis la oswa retire konsantman nèt nenpòt lè.

Eksepsyon: Tanpri fe ronn pou infomasyon ki “ka” oswa “pa ka” anba a.

Pwoblèm sa yo espesifik nan sante mwen KA / OSWA OU PA KA diskite.

Pwoblèm ki gen rapò ak maladi ki transmèt seksyèlman

Pwoblèm ki gen rapò ak gwosès

Pwoblèm ki gen rapò ak dyagnostik sikyatrik

Lòt pwoblèm

tanpri lis

Siyati pasyan(Required)

Dat

MM slash DD slash YYYY

East Florida Premium Medical Care is a trusted outpatient primary care practice located in Tamarac, Broward County, Florida. We proudly serve adults aged 18 and older,

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Home
About Us
Services
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Home
About Us
Services
Insurance Plans

Our Contact info

Address:
7421 North University Drive, Suites 301 and 314, Tamarac Florida 33321.

Telephone:
954 724 3440

Fax:
954 724 3494

Service hours

a. Monday, Wednesday, Thursday, Friday: 8:30 – 5:00 pm
b. Tuesday: 8:30 am to 7:00 pm
c. Saturday: 8:30 am to 1:00 pm