Avenues Location : CLOSED

10175 Fortune Parkway        Unit 402

Jacksonville, Fl 32256

CollegE: 904-644-8669

430 College Drive              Suite 100-102

Middleburg, Fl 32068 

Mon - Thurs: 8:00am-5:00PM FRi: 8:00am-12:00PM

we have made accommodations in the office to implement social distancing and ready to offer well child visits , vaccinations as before.

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Want to be a part of our growing Family at Excel Pediatrics?

Please complete the forms, print and bring them to your child's first visit . Please allow 15 extra minutes to assure completion of the registration process.  This will allow for you to spend the entire time of your scheduled visit with the provider instead of doing paperwork and administration tasks.

New Patient Forms

Before Scheduling a Home visit

Call 904-519-0008 to schedule a home visit with Dr Sue Tilak.  Home visits are offered for specific types of appointments (eg;  2 week well baby check up) on Friday mornings, every week.  These appointments require pre-payment at the scheduling time.

Home Visit Forms

Clearance for School Sports Participation

Print and complete the demographic and medical history part of the required form and bring it to the office visit for a smooth experience.

Athletic Pre-Participation Evaluation Form

Clearance for Procedures  with specialist

Print and complete the form with the medical history, medications,  and the procedure name, date, and place.  Please bring to the office visit for a smooth experience.

Pre-Procedural Evaluation Form

PHI use​

Custodial Parent: please print, complete and sign, prior to your child's first visit.

PHI Use Authorization Form

Release of Medical Information to OR from Excel Pediatrics

In the event that you need to obtain medical records from us or you need us to obtain medical records from your child's previous providers, please print, complete and sign.  You can then mail the form to us or drop it off at the office.

Medical Information Release Authorization Form

Authorization For Accompanying Adult for a Minor

Please print, complete, and sign this form to add someone or to update information for an existing authorized adult.  These are the people allowed to bring your minor child in for treatment, in your absence. Unless the form is completed and presented in person by a custodial parent, the form will required notarization to validate a custodial parent's signature.

Authorization Form for Accompanying Adult for Minor