• JOHN W. GRACE M.D.,P.A.

    CHECK-IN & PAYMENT FORM

    PART I

        We ask all patients to check-in with us monthly using Part 1 of this form.  If you are seeing a provider for an appointment we ask that you complete Part 2 of this form as well.   This will allow us to better use our time together and also keep your information up to date.   

        You will see a Green Check Mark and "Thank You! Your submission has been received." on the screen when this is done successfully. Please make sure you see this before exiting the screen, otherwise your form has not been submitted.

          NOTE:  FAILURE TO PROPERLY SUBMIT THIS FORM OR COMPLY WITH PAYMENT SCHEDULE BELOW MAY RESULT IN SHORTER SUPPLY OF PRESCRIPTIONS WHILE WE DETERMINE APPROPRIATE ACTION.

  • IMPORTANT ANNOUNCEMENTS
     

    SHORTAGE OF ADDERALL AND OTHER STIMULANTS

    There is a national and local shortage of Adderall and other stimulants.  Our reccomendation is that you come into the office for your appointments so that you can get a hard prescription that allows you to go to multiple pharmacies to find one that can fill your prescription.  Availability changes too rapidly to post such here.  

  • SURVEY ON CONTROLLED SUBSTANCES

    One of the possible unexpected results of dealing with the opioid crisis has been difficulty in filling legitimate and reasonable prescriptions. If you have been prescribed any controlled substances and are interested in taking a survey to help us improve our awareness and care please proceed by clicking link below. 

    SURVEY ON CONTROLLED SUBSTANCES

  • UPDATE ON APPOINTMENTS AND CONTROLLED SUBSTANCES 

    Two changes are likely coming:

    IN-OFFICE REQUIREMENT- PATIENTS WILL LIKELY REQUIRE TO BE SEEN IN OFFICE FOR EVERY OTHER ROUTINE VISIT.   THIS IS EVERY FOUR MONTHS ON ROUTINE CONTROLLED MEDICATIONS AND EVERY SIX MONTHS FOR OTHER PATIENTS.  

    REDUCTION TRIALS ON SEDATING AGENTS- EVERY SIX MONTHS WE WILL LIKELY REQUIRE A MODEST REDUCTION TRIAL OF SEDATING AGENTS TO DECREASE THE LONG TERM RISKS OF THESE MEDICATIONS.  

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  • MEDICATIONS NEEDED 

    *NOTE:  TRY TO GET THESE REQUESTS IN ABOUT SEVEN DAYS EARLY AS THERE CAN BE MULTIPLE DELAYS (MISCOMMUNICATIONS, SUPPLY, INSURANCE, ETC.) 72 HOURS AFTER YOU SUBMIT THIS FORM,  VERIFY THAT THE PRESCRIPTIONS ARE AT THE PHARMACY.  IF NOT, CONTACT DR. GRACE ON HIS CELL PHONE.

  • REMEMBER PAYMENTS

     You should be paying for your visit charge plus $20 towards any previous balance every month.   Failure to make agreed upon payments may result in decreased prescription duration while we determine whether ongoing care here is affordable for you.   

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  • BY YOUR SIGNATURE BELOW YOU AGREE TO THE FOLLOWING:

    1.  I am NOT currently a danger to myself or others.  Emergencies should be dealt with by contacting 911 or presenting to the nearest emergency room.  The Vines in Ocala, Springbrook Hospital, Shands Hospital.  

    2.  I have Dr. Grace's personal cell phone number and will contact him if there is a serious lapse in my care, understanding that he will return my call or deal with my issue within 24 hours. 

    3.  I have read and accept the policies and general instructions of John W. Grace, M.D.

    Link here:  https://www.johnwgracemdpa.com/instructions-policies 

    Including the following areas:

    POLICIES
    - PRIVACY

    - BALANCES, LATE CANCELATIONS, AND FEES

    - VISIT REQUIREMENTS AND TERMINATION

    - THIRD PARTY PAPERWORK

    - UNDERSTANDING AND MINIMIZING RISKS OF MEDICATIONS

     

    GENERAL INSTRUCTIONS

    HOW TO RELAX BY STRESSING YOURSELF OUT EACH MORNING.

    HOW TO BALANCE YOUR IMPROVEMENT

    HOW TO SEEK SERENITY MORE THAN EXCITEMENT

    HOW TO KEEP A GOOD ROUTINE

    HOW TO SEEK SUPPORT FOR GOOD DECISIONS

    HOW TO BE MORE MINDFUL

    HOW TO TRACK YOUR SYMPTOMS

    HOW TO AVOID DESTRUCTIVE IMPULSES

     

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  • JOHN W. GRACE M.D.,P.A.

    CHECK-IN FORM

    PART II

    If you are seeing a provider for an appointment we ask that you complete the second part of this form as well.   This will allow us to better use our time together and also keep your information up to date.   

     

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