Request an Appointment
Please do not use this form if you have an urgent medical problem or you need to reschedule an existing appointment. Instead, contact our office at (813) 653-1149. After you submit your request, our appointment scheduler will respond within 48 hours. See below for forms to complete.
Patient Registration Forms
Beth Ingram Therapy Services in Brandon, North Tampa, South Tampa, and Lakeland, Florida welcomes you to our practice. Once you have made your initial appointment, you may preregister by downloading, printing, and completing the forms below. Doing so prior to your visit will help speed up the new patient registration process.
Please be sure to bring all forms with you to your first visit, along with any diagnostic films or other test results that may have been ordered or performed by another physician.
Downloadable Forms:
- Pediatric Patient Registration
- Authorization to Release Personal Health information
- HIPAA Privacy Notice
- Teletherapy Consent Form
- Credit Card Authorization Form
- Financial Policy
- Forma de Registro Para Pacientes Pediátricos
Please note: It may take a few minutes to load the forms if you are using a slow internet connection. If you are unable to view the forms, you may need to download Adobe Acrobat for free by clicking on the icon below.
