Patient Registration

How to become a patient here:

Ask your primary care provider for a referral. The referral form can be found here.

Once a referral has been sent, along with the relevant records, (this may take a few days for labs, imaging, etc to come back), we will call you to schedule your first appointment.

What do you need to do?

  1. Watch for a call or voicemail from 256-284-7280.

  2. Watch for new patient paperwork to arrive by mail.

  3. Arrive 15 minutes early to your appointment at 153 Ana Dr in Florence.

Bring completed paperwork, filled out front and back, along with your ID and insurance cards, as well as a list of your medications.

Patient Registration Form

Please complete the form below:

Privacy Notice

We respect your privacy, the information requested on this page is solely to enable us to contact you regarding your health care. We will not sell or share your information for any marketing purposes, however as a convenience to you, we may provide your contact information to individuals or companies that will be providing care prescribed by this office (ex. Diabetes educator, diabetes pump trainer, etc).

Patient Information


Patient Portal

The Florence Endocrine Clinic provides an online patient portal which allows the patient 24/7 access to exchange messages with providers, view lab results, request appointments, view balance statement, etc. We will not spam you! This is the fastest way to receive lab results and/or contact a provider.

Insurance Information

Please present card to receptionist

Additional Info

Authorized Contacts

Please list anyone with whom the Florence Endocrine Clinic may discuss the patient’s care.

Authorized Consent

Health Insurance Portability and Accountability Act (HIPAA)
The patient consents to the use or disclosure of protected health information (PHI) by the Florence Endocrine Clinic, PLLC; for the purpose of diagnosing or providing treatment to the patient, obtaining payment for health care bills, or to conduct healthcare operations.
PHI includes health information, including demographic information, collected from the patient and created or received by the Florence Endocrine Clinic, another health care provider, a health plan, the patient’s employer, or a health care clearinghouse.

No-Show Policy:

The Florence Endocrine Clinic does maintain a no-show policy. While we understand that emergencies illness and accidents do happen we do appreciate the courtesy of a cancellation call text email or portal message. Patients who fail to cancel or reschedule an appointment beforehand may be assessed a $50 no-show fee. Repeat no-show appointments are grounds for patient termination.