Forms

At Mid-Florida Psychiatry Center, a TelePsychiatry virtual clinic, Dr Vangala has Physician Associates and Psychiatric Nurse Practitioners (AHP’s)who work along with Dr Vangala in seeing patients for medication management, either during initial visit or follow up visits. If an AHP has done assessment and unable to review with MD or the team are unable to come to conclusion of diagnosis and treatment plan, you may asked to schedule a follow up appointment prior to prescribing medication.

Also, Dr Vangala is teaching Medical students, PA students and Nurse practitioner students in this clinic. You may come across these students, who are just gathering the information and learning from either Dr Vangala or his AHPs. Please notify the staff if any specific requests.

By completing this paperwork, it’s implied that you are aware of the clinic setting/policy and are agreeing to be treated in this clinic.

Health History, Consent to Treatment and Other

Please fill out your contact information, insurance information, and health information to facilitate treatment, agreeing with clinics policies and procedures and agreeing to pay for services if your insurances declines or you have not met the deductibles, missed appointments, agreeing to consent for tele psychiatry visits and agreeing and consenting to treatment with medication as appropriate.

First Name

Last Name

Birthday

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Email

Phone

I have reviewed and accept terms & condition of Mid-Florida Psychiatry Center's EMAIL use policyhere...

Upload A Photo of Patient

Emergency Contact

Have Insurance?-Upload the Insurance cards

Yes

No

Private Pay

Upload Govt Issued ID (Front)

Relationship

Emergency Conact Phone

Insurance Name

Member ID

Group ID

JPG, PNG, GIF, JPEG, JPE, JFIF, BMP, HEIC, HEIF, TIFF, TIF, WEBP, JPEG 2000 and RAW.

Insured

Ins Card Front

Ins Card Back

I accept and agree for a NO SHOW fee of $35-unless I cancel my appointment 24 hours ahead of the actual appointment time.

I have reviewed and accept terms & condition of Mid-Florida Psychiatry Center's TELEPSYCHIATRY policyhere...

Who is your PCP?

Your PCPs Phone

I do consent for release of my medical, psychiatric, substance use and other pertinent/ sensitive information to/ from with Mid-Florida Psychiatry Center. I further understand that I can revoke this consent at any time with written means.

What is the reason for visit

How long you have this problem

CURRENTLY taking Psychiatric medication?

Yes

No

CURRENTLY Seeing a Psychiatrist?

Yes

No

Any PAST Psychiatric Admissions to Hospitals?

Yes

No

Any PAST Counseling/ Treatment-OUT Patient

Yes

No

Any PAST Psychiatric medication?

Yes

No

Any PAST Suicide Attempts?

Yes

No

Do You Smoke?

Yes

No

Do You Drink Alcohol?

Yes

No

Do You use any Drugs

Yes

No

Are you ALLERGIC to any medication?

Yes

No

Dont Know

Your Pharmacy name

Pharmacy Phone

Marital Status

Education

List your ALL CURRENT Medication

Children

Work Status

Abuse History

Legal History

Anyone in the Family has/had Psychiatric Problems

Yes

No

Dont Know

This is a general consent to treat with psychotropic medication, though individual verbal consent will be obtained from each patient at the time of prescribing medication, changing medication. Read more on general class of meds, and their side effectsread more ...

Do you have additional document to Upload?

Additional Documents

I have reviewed and accept terms & condition of Mid-Florida Psychiatry Center's HIPAA Pricay Ptractices Noticehere...

Vidyasagar Vangala, MD; FAPA

Forms

Health History, Consent to Treatment and Other

Click here for: Telepsych consent and Medication consent form-

* CLICK here for All forms, if you want to complete in handwriting, than completing the above

**If you have a guardian, to sign on your behalf- Guardian to complete additional forms here...

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