Kim Dumas, APRN

Family Practice

6128 S. Tamiami Trail
Sarasota, FL 34231
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Phone: (941) 923-5882

Fax: (941) 923-3836

Education: University of Alabama, Huntsville, AL

Certifications: Family Nurse Practitioner

Print Your Forms and Save Time

Please print & complete documents 1-5

1A. Adult Health History Questionnaire

or

1B. Pediatric Health History Questionnaire

2. New Patient Registration

3. Consent for Treatment

4. Consent to Leave Messages

5 Authorization to Release Medical Records

*Some additional paperwork must be completed at office

Medicare Annual Wellness Visit

1. Health Risk Assessment (HRA)

Reference Documents

1. Notice of Privacy Practices

2. Making Personal Choices Information

3. Living Will Documentation

FPG Navigator

A password-protected Web portal that gives you 24-hour access to certain personal health information from your FPG medical record. For urgent requests, phone your doctor’s office. Call 911 for emergencies.

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About
Contact

Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact Sarasota Memorial Health Care System Public Relations Offices by phone or in writing:

ADMINISTRATION OFFICE:

1700 S. Tamiami Trail (mailing address); 1900 S. Tamiami Trail (physical address)

PRIVACY POLICY:

Please click here to read our Privacy Policy. | Nondiscrimination Statement

CONSUMER DATA:

Agency for Health Care Administration
Centers for Medicare / Medicaid Services