Gardens Internal Medicine

Use the name and sex on your insurance card. Answers stay on this device until you send them. You can close this and come back.

Patient identity

Legal last nameLegal first nameMiddleOptionalDate of birthLegal sexAs on insuranceMarital statusOccupationOptional

Mobile phoneHome phoneOptionalEmail

Florida street addressCityStateZIPOther addressSeasonal or out of stateMonths in each placeIf you live in two places

NameRelationshipPhone

Advance directive or living will?Healthcare surrogate or POA? (typically, this is a 'no')

Preferred pharmacyPharmacy phoneOptional

Required. Where you prefer blood draws.

Quest DiagnosticsLabcorpJupiter Medical Center (Margaret Niedland center laboratory)

Optional.

Preferred imaging center