813.365.3525

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.

NPR_2017.pdf
Adobe Acrobat document [98.6 KB]

APPOINTMENT REQUEST FORM

For faster scheduling, please fill up the form below:

Your form message has been successfully sent.

You have entered the following data:

Appointment Request Form

Please correct your input in the following fields:

Error while sending the form. Please try again later.

First & Last Name *

Street Address, City, State & Zip Code: *

Cellphone/Home Phone *

E-mail address: *

Date of Birth *

Insurance Company Name *

Policy/Member ID # *

Group ID # *

Subscriber Name & Date of Birth *

Insurance Contact No. (Please check the back of your card) *

May we send you appointment reminders through your cellphone?

What is the reason for the appointment? *

When is your preferred date and time of appointment ? (options 1, 2 & 3) *

How did you hear about us? (referring physician, friend, family, employers, community, church newsletter, internet, etc.)

Captcha (spam protection code) *

Note: Fields marked with * are required

PAY ONLINE 24X7. https://pay.instamed.com/ALVIOR.MED

1905 W. Busch Blvd.

Tampa, FL 33612

Phone: 813.365.3525

Fax: 813.365.3515

Clinic Hours:

Tues/Thurs/Fri

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.

Logout Edit page