Patient Registration Form

New Patient Registration

Patient Information:
First Name:
Last Name:
Date of Birth:
Gender:
Marital Status:
Social Security Number:
Contact Number:
Email:
Address:
City:
State:
Zip Code:

Emergency Contact:
Emergency Contact Name:
Relationship to Patient:
Emergency Contact Number:

Insurance Information:
Primary Insurance Provider:
Primary Policy Number:
Primary Group Number:
Secondary Insurance Provider:
Secondary Policy Number:

Health History:
Allergies:
Chronic Conditions:
Current Medications:
Past Surgeries:
Family Medical History:

Lifestyle Information:
Smoking Status: Current SmokerFormer SmokerNever Smoked
Alcohol Consumption: RegularlyOccasionallyNever
Exercise Frequency:

Authorization and Consent:
I authorize the use and disclosure of my health information as described in the Privacy Notice.
I consent to the examination and treatment by the healthcare providers at this facility.

Office Locations:

Opening Hours

Meet Our Endocrinologists

Our Endocrinologists, Dr. Carlo A. Fumero, Sean Amirzadeh, DO, Alberto Garcia Mendez, Lauren Sosdorf, and Pedro Troya, are board certified by the American Board of Internal Medicine and have a wealth of experience treating thyroid conditions. They will work with you to create a personalized treatment plan that meets your unique needs.

OUR TESTIMONIALS

What our patients say about us

As a patient of Dr. Troya’s for several years, I would highly recommend this endocrinologist to anyone. He gives full attention to you and your needs without being pressed for time. His diagnosis and treatments are thorough with up-to-date technology and years of experience. His concern and compassion are genuine with your best interest at heart. After having multiple biopsies performed by Dr. Troya, I am definitely a loyal follower.

I have been going to Dr. Troya for a year. He has treated my Diabetes with great success. He communicates with my other doctors, so he has a complete medical history of all my health issues. We need more caring doctors like Dr. Troya who has the patient’s best interest at heart. I am very thankful for Dr. Pedro Troya.

I was a private pilot for 34 years before contracting Type 1 diabetes after a severe case of food poisoning in March of 2008. My first endocrinologist refused to assist me in working with the FAA to retain my pilot’s license. I became a patient of Dr. Troya in 2010. Since that time, he has put me on a Continuous Glucose Monitoring regime and helped me stabilize my blood glucose levels to levels that allow me to pass my FAA medical exam. His caring and interest in each patient's personal issues, as well as their medical outcomes, marks him as an outstanding physician.

Dr. Carlos Fumero is a very personable and caring physician. He takes the time to listen and is very thorough in his evaluations and explanations. He exercises incredible care and concern. I have been referring family members and friends to Dr. Carlos Fumero for almost two years now. We are all exceptionally grateful to have found such a trusted physician. Thank you, Dr. Carlos Fumero. Your kindness and medical expertise are more appreciated than I could ever express in words.

Need to speak with the Doctor? We’d love to hear from you!

Years of Experience

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Patient Registration Form

New Patient Registration

Office Locations:

Opening Hours

Meet Our Endocrinologists

OUR TESTIMONIALS

What our patients say about us

Company

Services

Operating Hours

Wesley Chapel Office: