Patient Forms

• Patient Authorization to Disclose Health Information
• Consent to Treatment and Care of Minors
• Medical Records Request Forms
• Disability Forms
• Lifetime Signature Authorization
• Surgery Center Patient Satisfaction Survey
• Rehabilitation Center Patient Satisfaction Survey

Dr. Bernasek's forms cannot be downloaded from our Web site and will be distributed upon your arrival for your appointment.

• First Visit Questionnaire (Spine)
• Initial Evaluation (Hand Patients)
• New Patient Exam Form (To be completed by all patients)

New Patient paperwork cannot be downloaded from our Web site. The following forms are for follow up surgery patients only.

• First Visit Questionnaire (Spine)

• Initial Evaluation Form

Please contact Florida Orthopaedic Institute prior to printing and filling out forms to verify which forms are required for your appointment.

• Initial Evaluation Form

• Patient Questionnaire

New Patient paperwork cannot be downloaded from our Web site. The following forms are for follow up patients only.

• Pre- and Post-op Shoulder Form
• Pre- and Post-Op Shoulder Form (Español)
• Preop Elbow & Post Op Elbow Patients
• Pre- & Post-Op Implant Patients
• Pre- & Post-Op Implant Patients (Español)

• Patient Questionnaire
• Pediatric Form

• New Patient Questionnaire

Please contact Florida Orthopaedic Institute prior to printing and filling out forms to verify which forms are required for your appointment.

• Initial Evaluation Form

• Initial Evaluation
• Medical Records Release

• Patient Questionnaire / Initial Evaluation
• Pediatric Form

Please contact Florida Orthopaedic Institute prior to printing and filling out forms to verify which forms are required for your appointment.

• Initial Evaluation Form

• First Visit Questionnaire (Spine)

• Patient Questionnaire

• Shoulder Patient History Form
• Elbow Patient History Form

Michael A. Miranda, D.O. — Adult Reconstruction & Arthritis Surgery / Hip / Knee

All new patients coming in need to fill out the forms upon arrival.

• Patient Questionnaire Evaluation Form
• Patient Follow-Up Form

• Initial Evaluation Form

Please contact Florida Orthopaedic Institute prior to printing and filling out forms to verify which forms are required for your appointment.

• First Visit Questionnaire

• First Visit Questionnaire
• Pain questionnaire

• Upper Extremity Patient Questionnaire

• Patient Questionnaire

• Patient Questionnaire / Initial Evaluation

Every patient is required to complete one or two of the forms listed below. If you are unsure of which forms to print and complete, please contact Florida Orthopaedic Institute's scheduling department for further instructions at (813) 978-9797.

• First Visit Questionnaire (To be completed for your initial visit)