[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-284063-105":53,"doc-detail-284063-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","initial-patient-visit-form-medical-associates-of-brevard","Initial Patient Visit Form - Medical Associates of Brevard","","This document serves as an official initial patient registration and medical consent form for Medical Associates of Brevard, specifically for the practice of Sharad Vyas, M.D. It is designed to collect comprehensive patient demographics, parent or guardian contact details, racial and ethnic background, preferred language, and pharmacy information. Additionally, the form includes sections for primary and secondary insurance verification, referral source tracking, and a formal medical consent authorization section. This consent portion allows parents or guardians to designate authorized individuals who are permitted to bring a minor child to medical appointments and make healthcare decisions on their behalf, ensuring proper compliance with medical facility policies and HIPAA release requirements. The document functions as a standard administrative tool to streamline patient onboarding, ensure accurate record-keeping, and maintain legal authorization for the medical care of minor patients within the clinical setting.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/initial-patient-visit-form-medical-associates-of-brevard/284063/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/initial-patient-visit-form-medical-associates-of-brevard/284063.png","ImageObject",442,249,{"name":88,"@type":89},"Valentina","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":30},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required for the parent or guardian of the patient?","Question",{"text":108,"@type":109},"The form requires the parent or guardian's full name, address, Social Security number, date of birth, cell phone number, and email address.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What is the purpose of the Medical Consent Form for Minor Child?",{"text":113,"@type":109},"It provides permission for specific individuals, designated by the parent or guardian, to bring a minor child to medical appointments and make healthcare decisions for them.",{"name":115,"@type":106,"acceptedAnswer":116},"What specific insurance details are needed on the form?",{"text":117,"@type":109},"You must provide the names of both primary and secondary insurance companies, the policy numbers, the policy holder names, their dates of birth, and their Social Security numbers.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},284063,1789988361,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":30,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},13056703020460,"https://ap-avatar.wpscdn.com/avatar/be000253dac470eee5d?_k=1778207105932848923","SHARAD RVYAS, MD  \n2186 Harris Ave NE Suite 2, Palm Bay, FL 32905 321-725-8111  \nPatient Name: First: Middle: Last:  Address: City: State: Zip:  Date of Birth:  / /  Gender:   Soc Sec \\#   -  -  PARENT/GUARDIAN’S INFORMATION:  \nMother’s Name: First: Middle: Last:  Address: City: State: Zip:  Soc Sec \\#   -  -   Date of Birth:  Cell Phone:  Email:  Father’s Name: First: Middle: Last:  Address: City: State: Zip:  Soc Sec \\#   -  -   Date of Birth:  Cell Phone:  Email:  Patient’s_Race: American Indian_or_Alaska_Native: ⃝ Asian: ⃝ Native Hawaiian: ⃝ White: ⃝  \nBlack or African_American: ⃝ Other Pacific Islander: ⃝ Prefer not to answer: ⃝  \nEthnicity: Hispanic/Latino: ⃝ Non-Hispanic/Latino: ⃝ Prefer not to answer: ⃝  \nPrimary Language:_English: ⃝ Spanish: ⃝ French: ⃝ Indian: ⃝ Other: ⃝  \nPreferred Pharmacy: Location Phone:   \nInsurance Information: Primary Insurance Co: Policy\\#  \n________________________________ ______________________  \nPolicy Holder Name: DOB: / / Soc. Sec    Secondary Insurance Co: Policy\\#   \nPolicy Holder Name: DOB: / / Soc. Sec.\\#   \nPatient referred by:  Self referral: Yes ⃝ No ⃝  \nWe ask all patients to show their insurance cards and a parent/guardian picture ID so we may take copies  \nMEDICAL CONSENT FORM FOR MINOR CHILD  \nName of Child:    \nDate of Birth:   \nThe following individuals have my permission to bring above named child to doctor appointments and make all medical decisions for the child.  \n(1 )Name:  Relationship:   \nTel:   \n(2) Name:  Relationship:   \nTel:   \n(3) Name:  Relationship:   \nTel:   \nSignature:   Date:   \nName of Parent/Guardian: (Please Print)    \nRelationship to Child:    \nPlease add the above person/persons who have permission to bring the child to the  \nHippa release form on the next page.","cbCaijYAuVz1ZfRy","https://ap.wps.com/l/cbCaijYAuVz1ZfRy","pdf",645680,"English","# Patient and Guardian Information\n## Demographic and Contact Details\n## Insurance and Referral Data\n# Medical Consent for Minor Child\n## Authorized Individuals for Appointments\n## Legal Authorization and Signature","[{\"question\":\"What information is required for the parent or guardian of the patient?\",\"answer\":\"The form requires the parent or guardian's full name, address, Social Security number, date of birth, cell phone number, and email address.\"},{\"question\":\"What is the purpose of the Medical Consent Form for Minor Child?\",\"answer\":\"It provides permission for specific individuals, designated by the parent or guardian, to bring a minor child to medical appointments and make healthcare decisions for them.\"},{\"question\":\"What specific insurance details are needed on the form?\",\"answer\":\"You must provide the names of both primary and secondary insurance companies, the policy numbers, the policy holder names, their dates of birth, and their Social Security numbers.\"}]","Initial Patient Visit Form - Medical Associates of Brevard | PDF",1789628109]