New Patient Registration Form

     For your convenience, new patient registration forms may now be downloaded from this page. 


     Please complete the form to the best of your knowledge, and bring any supplementary but vital information (list of current medication, allergy list,  most current laboratory test results, diagnostic test results, etc.) with you on the day of your initial visit.  This ensures that all or most  of your medical information relevant to the purpose of your visit is supplied to the doctor, providing the doctor a more comprehensive overview or your current medical situation and  therefore making your initial visit more satisfying.


     Also, please remember to bring your insurance card and valid ID picture card on the day of your visit.

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For faster scheduling, please fill up the form below:

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Appointment Request Form

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1905 W. Busch Blvd. 

Tampa, FL 33612


Phone: 813.365.3525

Fax: 813.365.3515


Clinic Hours:  


9:00 AM - 4:00 PM

Wed 2:00 PM - 7:00 PM


The Clinic is open on Mondays from  9am-4pm for administrative purposes only.

We are TELEMEDICINE capable!  Please call to set up an appointment.

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