Quick Primary Care
Ocala, FL 34481
Phone: 352-854-9110
Fax: 352-854-9119
QPC Forms
Complete all nine pages in order using the links below (use Continue on each page to keep your session). When you finish page 9, a combined PDF of your registration is emailed to you and our office (if notifications are enabled).
New Patient Intake Form
QPC New Patient Intake Form
Page 1 of 9
Patient intake
Physician, demographics, insurance, emergency contact, and signature.
Open formPage 2 of 9
Allergies & medications
Allergies, medications, and preferred pharmacies.
Open formPage 3 of 9
Social & lifestyle
Social history, screenings, and related health questions.
Open formPage 4 of 9
Family history
Family medical history matrix.
Open formPage 5 of 9
Habits
Smoking, alcohol, coffee, and exercise.
Open formPage 6 of 9
Office policies
Practice policies and patient agreement.
Open formPage 7 of 9
Privacy authorization
Privacy authorization and witness signature.
Open formPage 8 of 9
HIPAA authorizations
Lifetime HIPAA authorizations and authorized persons.
Open formPage 9 of 9 — Final
Records release
Medical records release. Completing this page finishes registration.
Open formOther forms
Individual forms for declining specific screening services.
Cognitive screening
Clock drawing test
Draw a clock face as instructed.
Open formDepression screening
PHQ-9
Patient Health Questionnaire — 9 item depression screen.
Open formRefusal form
Bone density screening
Decline bone density screening.
Open formRefusal form
Cervical screening
Decline cervical cancer screening.
Open formRefusal form
Colorectal screening
Decline colorectal cancer screening.
Open formRefusal form
Mammogram screening
Decline mammogram screening.
Open form