New Patient Intake — Dr. Ambrosio Jesus Romero, M.D.

1

Patient Information

Basic demographic and contact details

Last Name *

First Name *

Middle Initial

Date of Birth *

Phone Number *

Email Address

Street Address

City

ZIP Code

Sex at Birth

Preferred Language

2

Authorization to Communicate PHI via Electronic Means

HIPAA § 164.501 — Required to contact you about your care

I authorize Dr. Ambrosio Romero to communicate with me via the following electronic means. Please check your preferred method(s) and provide contact information.

Authorize	Method	Contact Information
	💬 Text
	✉️ Email
	📹 Video Conference

I do not authorize Dr. Ambrosio Romero to communicate with me via electronic means.

This Authorization expires:

Upon written revocation Other

I understand that by selecting communication methods above and signing, I authorize Dr. Ambrosio Romero to share PHI information via electronic means. I understand that according to HIPAA Privacy Rule § 164.501, Dr. Romero cannot sell or distribute my communication information without prior consent. I understand I may refuse to sign and cannot be denied treatment for doing so.

Patient Signature *

[ Sign here — print & sign on paper form ]

Date:

3

Generalized Anxiety Disorder Screening (GAD-7)

Over the last 2 weeks, how often have you been bothered by the following?

Problem	Not at all (0)	Several days (1)	More than half (2)	Nearly every day (3)
1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

Total Score: —

5–9: Mild Anxiety

10–14: Moderate Anxiety

15+: Severe Anxiety

4

Patient Health Questionnaire (PHQ-9)

Over the last 2 weeks, how often have you been bothered by the following?

Problem	Not at all (0)	Several days (1)	More than a week (2)	Nearly every day (3)
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading or watching television
8. Moving or speaking so slowly others could notice — or being fidgety or restless more than usual
9. Thoughts that you would be better off dead, or of hurting yourself

Total Score: —

10. If you checked off any problems, how difficult have these made it to work, manage home, or get along with others?

Not difficult at all Somewhat difficult Very difficult Extremely difficult

1–4: Minimal

5–9: Mild

10–14: Moderate

15–19: Mod. Severe

20–27: Severe

5

Credit Card Authorization

Monthly membership billing — $72/month flat rate

🔒 Dr. Romero's pledge: Your cardholder information is treated with the utmost care and confidentiality. This sensitive data is accessible only to Dr. Romero personally and will not be shared with any unauthorized individuals or entities.

Card Type *

MasterCard VISA Discover AMEX Other

Cardholder Name (as shown on card) *

Card Number *

CVV *

Expiration Date (MM/YY) *

Cardholder ZIP Code (billing address)

I authorize Dr. Ambrosio Romero to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account. This authorization will remain in effect until cancelled.

Customer Signature *

[ Sign here — print & sign on paper form ]

Date:

6

Accurate Information & Pharmacy Form

Required for seamless prescription processing

Please verify the information below matches your pharmacy records exactly. This ensures your prescriptions are processed without delay.

Full Name (as on pharmacy file) *

Date of Birth *

Phone Number *

Address

Height

Weight

Email Address

Known Allergies *

Default Pharmacy Information

Pharmacy Name *

Pharmacy Address

Pharmacy Phone Number

Pharmacist Name (if known)

7

Patient Responsibility & Controlled Substance Agreement

Required only if controlled substances are prescribed

⚖️ Florida Law Notice: The Florida Legislature governs the prescription of controlled substances. Controlled substance medications (narcotics, benzodiazepines, sleep aids, stimulants, barbiturates) have high potential for misuse and are closely regulated by local, state, and federal governments.

Controlled substance being prescribed (if applicable)

By checking below, I acknowledge and agree to the following:

I understand the risks of psychological and/or physical dependence associated with controlled substances. Only Dr. Romero will prescribe my controlled substances. I will not obtain them from any other provider. Prescriptions are for a 30-day supply only and can only be refilled during scheduled appointments. All medications must be filled at the same pharmacy when possible. I agree to routine blood work and random urine drug (NIDA-9) testing when requested. Lost, stolen, or misplaced controlled substances cannot be replaced or refilled early. I understand that driving may not be allowed while taking certain controlled substances. It is a crime to obtain controlled substances under false pretenses. I understand all confidentiality may be waived if this agreement is violated. I have read this agreement in its entirety and agree to follow these guidelines as explained by Dr. Ambrosio Romero.

Printed Patient Name *

Date of Birth

Patient/Guardian Signature

[ Sign here — print & sign on paper form ]

📄

Download & Print Original Forms

For your records or to complete by hand

📋

Complete Patient Authorization Packet

Includes: PHI Authorization · GAD-7 · PHQ-9 · Credit Card Authorization · Pharmacy Form · Controlled Substance Agreement

⬇ Download PDF

💡 Easy way to sign digitally: Go to www.sejda.com → upload this PDF → complete and sign online for free → download → email to ambrosioromeromd@gmail.com

Welcome toYour New Practice.

Patient Information

Authorization to Communicate PHI via Electronic Means

Generalized Anxiety Disorder Screening (GAD-7)

Patient Health Questionnaire (PHQ-9)

Credit Card Authorization

Accurate Information & Pharmacy Form

Default Pharmacy Information

Patient Responsibility & Controlled Substance Agreement

Download & Print Original Forms

Complete Patient Authorization Packet

Welcome to
Your New Practice.