Guillermo Marrero, MD.,P.A.

Please print and fill out as need it the following forms and bring it with you to your first appointment.( print only 1 to 8, do not bring #9)

	1. Patient Information	6. Consent of Treatment

	2. History Review of Systems	7. Authorization

	3. Notice Receipt Acknowledgement	8. SECTION C: Expiration & Revocation

	4. Authorization for Release of Medical Records	9. Notice of Privacy Practices

	5. Financial Agreement

LABORATORY CLOSEST TO OUR OFFICE

		LABCORP 1000 W BROADWAY ST. OVIEDO, FL 32765 Phone: 407-359-2132 Fax: 407-359-2176			Quest Diagnostics-Oviedo 1950 W Sr 426 Ste 108 Oviedo,Fl 32765-9145 Phone: 407-977-2098 Fax: 407-977-8921
				You may also locate a facility by telephone: 800-377-8448