Patient Forms

Once you have made your initial appointment, please be sure to visit our Patient Portal to complete your registration and all of your medical history and information. You may also download, print and complete the forms prior to your arrival. The online Patient Portal will help you speed up the new patient registration process and get you in to see the doctor faster!

Please download the Medical History form below, please fill it out completely, bring it with you completed. When you arrive at your appointment you will also be asked to use our new electronic Phreesia Check-In System. Which will expedite your check-in process at Orthopaedic Specialties.

Downloadable Form

Orthopaedic Specialties New Patient Paperwork

Suite C:

Mitchell R. Herrema, D.O.
Matthew Benson, PA-C
Richard S. Howell, M.D.
Zachary Serbu, PA-C

Suite D:

Allison Burgess, PA-C
Anthony Marcotte, D.O.
Robert Franceskino, PA-C
Michael Venezia, D.O.

Please bring the following items to your first visit at Orthopaedic Specialties of Tampa Bay:

  • PHOTO ID (Driver’s License, State ID, etc.)
  • Any outside films and/or diagnostic reports
  • Lab results
  • Insurance cards
  • Co-pay
  • Medication list including strengths/dosage
  • Printed and completed Medical History Form (See above)

Thank you!