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 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. 

Upload A Photo of Patient
Have Insurance?-Upload the Insurance cards
Upload Govt Issued ID (Front)
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Ins Card Front
Ins Card Back
CURRENTLY taking Psychiatric medication?
CURRENTLY Seeing a Psychiatrist?
Any PAST Psychiatric Admissions to Hospitals?
Any PAST Counseling/ Treatment-OUT Patient
Any PAST Psychiatric medication?
Any PAST Suicide Attempts?
Do You Smoke?
Do You Drink Alcohol?
Do You use any Drugs
Are you ALLERGIC to any medication?
MEDICAL CONDITONS
MEDICAL CONDITONS
SURGERIES
PSYCHIATRY CONDITONS
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Anyone in the Family has/had Psychiatric Problems
Additional Documents
Additional Documents
Click here for: Telepsych consent and Medication consent form-