New Patient Request

Welcome to your new Medical Family!

Welcome to Medical Partners of Florida, your new Medical Home. Founded in 2006, we are Floridas most comprehensive Holistic Health and Wellness group dedicated to providing comprehensive care to communities throughout the state of Florida. With a focus on treating the whole person rather than just symptoms, we offer a wide range of services designed to promote optimal health and well-being. Our family of healthcare practices include Holistic Primary Care of Brevard, Viera Functional Medicine, Florida Sports & Spinal Rehab, and Verde Medical Group.
Our Services...

At Medical Partners of Florida, we believe in a patient-centered approach that integrates traditional and alternative medicine to address the root causes of health issues. Our Primary Care services ensure that patients receive routine check-ups, preventive care, and management of chronic conditions with a personalized touch. Through Functional Medicine, we delve deeper into understanding the underlying factors contributing to illness, offering tailored treatments that enhance the body’s natural healing processes.Our Physical Therapy and Chiropractic Care services focus on restoring mobility, relieving pain, and improving overall function, helping patients regain their quality of life. Additionally, our Medical Massage therapy provides therapeutic benefits, reducing stress, and promoting relaxation and recovery.
First step towards OPTIMAL HEALTH!

The first step to becoming a new patient is to get you registered in our system. Please take a few minutes to fill out our New Patient Inquiry form so we can get the ball rolling. This form will be used by our Patient Care Services team to understand the services you are interested in, while also providing our billing team with the necessary information to verify your health insurance coverage and benefits, ensuring we are all on the same page from a coverage standpoint.Don't worry—if your insurance plan does not cover certain services, or if you do not have insurance at all, our Patient Care Services team will discuss cash pricing and payment plans that meet your financial needs. Our goal is to ensure that you receive the care you need, and this information helps us manage the financial aspects of care so there are no surprises.
What services are you interested in? (check all that apply)*

PRIMARY CAREFUNCTIONAL MEDICINEPHYSICAL THERAPY & REHABILITATIONCHIROPRACTICE CAREMEDICAL MASSAGEOther
How did you hear about us? (check all that apply)*

Referred by Physician or other Medical ProviderNatural Awakenings MagazineViera Voice NewspaperSpotlight MagazineGoogle AdvertisementOnline SearchReferred by Existing Patient (Friend or Family member)Other
Do you currently have a Primary Care Provider?*

YesNo
List Current or Last Primary Care Provider below.
Primary Care Provider Name
Specific conditions or issues that you are looking to address?
PERSONAL INFORMATION

Please complete the attached sections with your personal information. This information will be used to build your profile and ensure efficient scheduling. Your privacy and security are our top priorities and we will not use this information for anything other than building your medical profile in our medical records system.
Patient Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Gender*
Insurance Information

Many of our services are covered by health insurance and we are in network with many major insurance plans. To ensure coverage, we require verification of your insurance benefits before scheduling your appointment. This process helps confirm your coverage and allows us to provide you with accurate billing information, ensuring there are no unexpected costs. If you don't have insurance or have a high deductible plan, we have cash packages that can meet most everyones needs. Please take a few minutes to provide us with your insurance information on the form below.
Do you have any of the following: Health Insurance, Health Savings Account, Flex Spending Account, etc? (check all that apply)*

Health InsuranceHealth Savings AccountFlex Spending AccountNone of the Above (Cash Pay / Payment Plan)
Primary Insurance Co*
If no insurance, enter proposed payment type.
Policy No*
If no insurance, enter "NONE".
Group No*
If no insurance, enter "NONE".
Primary Insurance Phone No*
If no insurance, enter "NONE".
Primary Policy Holder Name (You / Spouse / Etc.)*

First NameLast Name
Primary Policy Holder Date of Birth*

MonthDayYear
If no insurance, enter "01-01-2024".
Primary Policy Holders Relationship to Patient*
If no insurance, enter "NONE".
Secondary Insurance Co (if any)
Secondary Policy No (if any)
Secondary Group No (if any)
Secondary Primary Policy Holders Name

First NameLast Name
Secondary Primary Policy Holders Date of Birth

MonthDayYear
Date
Secondary Primary Policy Holders Relationship to Patient
Take a Photo (Front of Insurance Card)
Take a Photo (Back of Insurance Card)
Any additional information you would like to share before we get things rolling?
Should be Empty:

Welcome to your new Medical Family!

Our Services...

First step towards OPTIMAL HEALTH!