Bread & Roses Woman's Health Center

Bread & Roses Woman's Health Center

1560 South Highland Avenue Clearwater, FL 33756
Consultation Appointment ONLY - appointments take 2-3 hours*
Bring photo ID.

Expect an appointment duration of 2-3 hours on the consultation day.

Form of payment is due on day of consultation. (No personal checks)

No small children allowed in the clinic.
Contact Information
Name*

First NameLast Name
Date of Birth*
(mm/dd/yyyy)
Phone Number*
Please enter a valid phone number.
Email*
example@example.com

Medical Information
First day of your last menstrual period?*
(mm/dd/yyyy)
Any medical problems that we need to know about?*
Current medications ? *
medication, dosage, frequency
Drug allergies?*
Which option would you like to do ?*
Do you need financial assistance to cover your services?*
Please verify that you are human*
If you need to reschedule your first consultation appointment after you have already submitted this form,

Please call our clinic phone number at 727-446-2690

for further assistance. Thank you
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Contact Information