Forms

Daily we receive a high volume of requests for forms to be completed.  Some of the most common ones are School Physicals (State of Florida Gold Form), Shot Records (State of Florida Blue Form), Sports Physicals (FHSAA Form), Medication Authorizations for School (Polk County School Board Form), WIC Forms and requests for Prescription Refills.  We are happy to complete these for you as part of our usual services. Completion of these forms sometimes requires an office visit for a current well care visit or chronic problem assessment.  For reasons of medical information privacy we do not fax completed forms.  Forms may be picked up by the parent or legal guardian, and prescriptions for controlled substances will require ID and a signature at the time of pick up.

We request  7 to 10 business days to complete most forms.  All of our physicians and nurse practitioners see patients at both offices so many times the provider who needs to complete the form will not be immediately back at the location where the form(s) are to be picked up.

The following links are helpful to parents new to our practice:

For your convenience, you may print and complete these forms and bring them with you to your first appointment.

  1. Blue and Gold Forms cannot be completed unless we have seen your child for a Well Visit in the past 12 months and their shots are up to date.  We do utilize the Florida SHOTS system, which is a State of Florida registry for immunizations, to ensure your child is current on their required immunizations.
  2. Sports Physical Exams must be performed after June 1 of each new school year according to the Polk County School Board.  Sports Physicals require different clinical evaluations than a standard well visit so sometimes an additional physical appointment will be required.
  3. Medication Authorizations are required by Polk County School Board for administration to your child by the school nurse.
  4. WIC Forms must be completed prior to your visit to WIC so please allow time for the forms to be completed and picked up prior to your appointment with WIC.
  5. Prescription Refills will be reviewed by the prescribing provider prior to refills.  In some case you may be required to bring your child in to see the provider in order to get a refill. Any child receiving medication for a chronic problem (e.g. asthma, allergies, ADHD) will need to be seen at a minimum every 6 months and sometimes more often at the discretion of the prescribing physician.New patient’s requesting medication refills will need an office evaluation and in many cases medical records will need to be obtained. Past medical records are always necessary for prescription of controlled medications, such as ADHD drugs.If you are already an established patient and have a secure Follow My Health Parent Portal account with us, you may request a prescription refill.If you have not yet signed up for the Follow My Health Parent Portal, please call 863-577-1919 and leave a message on our dedicated “Follow My Health” voicemail. Our staff will then send a personal invitation for you to access this feature.