AICC
Office Location:
320 S.R. 60 East
Suite 101
Lake Wales, FL 33853
Tel: 863.679.7985
Fax: 863.679.1865

Patient Forms

First time patients please download and complete:
• Protected Health Information Release Form
• Patient Information Form
• Financial Policy
• e-Prescribing Consent Form
Bring all four forms completed and signed to your first appointment
Please bring your insurance card/s and a picture ID
Bring all medication bottles
Make sure you read the "Notice of Privacy Practices"


  • EPRESCRIBE CONSENT FORM

  • FINANCIAL POLICY

  • MEDICAL RECORDS REQUEST

  • NOTICE OF PRIVACY PRACTICES

  • PATIENT INFORMATION FORM

  • Copyright © 2004-2017 AICC All Rights Reserved.