Forms


 

What you need:

• New Patient Forms - must be updated yearly

For New Patients or Updates: Please download this .pdf file. Fill it out to save time when coming in for a visit. (Patient Information Form, Medical Information Form and Review of Symptoms, Financial Policy and HIPAA Notice of Privacy.)

Patient Intake Form

 

What to Bring:

• Patient Registration Forms

Click above on Patient Intake form. You will need to fill them out and bring them with you to your appointment.

 

• Insurance Card(s) and a Photo ID

If the appointment is for a minor, you will need to provide the legal guardian's insurance card(s) and photo ID.

 

• Medical Records

Please bring relevant medical records from other physicians; results and copies of X-rays; and other imaging studies and lab tests and bring these items with you to your appointment.

 

• Written Lists of:

Medications, herbs, vitamin supplements and over-the-counter medications you are taking.

 

• Your Concerns:

About your condition (pains, loss of mobility or function).

 

• A Family Member or Friend

Consider asking a friend or family member to accompany you if you need any assistance in walking, using the restroom or filling out paperwork.

 

• Translator

If you need a translator, ask another adult to come with you; don't rely on a child to translate.

 

• Questions

Take the time to make a list of anything you may want to ask your physician regarding your condition.

 

• Comfortable Clothes

Your condition may involve X-rays. Wear loose clothing that's easy to take off and put on.

Location
Philip Regala, MD
1350 Tamiami Trail North, Suite 203
Naples, FL 34102
Phone: 239-325-1131
Fax: 239-262-5980
Office Hours

Get in touch

239-325-1131