Patient forms.
Download and complete these before your visit to save time at check-in. Bring the printed pages with you, or return them by fax to (321) 972-1132. If you'd rather fill them out here, arrive fifteen minutes early and we'll get you set up.
Authorization and Consent for Treatment
Your consent for us to provide evaluation and treatment. Required before your first visit.
Authorization for Release of Information
Authorizes us to share or request your medical records — use this to have outside imaging or notes sent to us, or ours sent elsewhere.
Preferred Contacts
Names the family members or caregivers we may speak with about your care.
HIE Opt-Out Request
Optional. Submit only if you wish to opt out of statewide Health Information Exchange record sharing.
Manage records and appointments online
Your visit summaries, results, and messages live in the Privia patient portal.
Privia patient login →Not sure which forms you need?
Call us and we'll tell you exactly what to bring for your appointment type.
(321) 972-1102 →These forms open as PDFs. If your device can't open them, call the office and we'll mail or email copies. Please don't send completed forms by regular email — fax them, or bring them with you.
Winter Park, FL 32789
Fax (321) 972-1132
The Renaissance Institute is a proud member of Privia Medical Group. The best doctors in our community have joined together to form Privia Medical Group (PMG), a multi-specialty, high-performance medical group that puts patients first. Our physicians are united by the mission of providing better, more coordinated care for their patients.
To learn more about Privia Medical Group and find other Privia doctors, please visit our website.