ADA Accommodation Request form
Tallahassee Orthopaedic Clinic, LLC, d/b/a Florida Orthopaedic Institute (“THE PRACTICE”)
Effective Date:
Return to: 1557/ADA Coordinator- Jennifer Corbin, jcorbin@ortho-solutions.com
Patient Information:
Full Name:____________________________________________________________________
Date of Birth:____________________________
Email (optional):________________________________________________________________
Preferred Contact Method (Phone, Patient Portal, Email, Mail, Other):_____________________
Visit Information:
- Date of Scheduled Appointment (if applicable):______________________
- Practice Location:________________________________________________________
- Provider/Department:_____________________________________________________
Accommodation Request:
☐Mobility assistance (wheelchair access, transfer help, accessible exam table)
☐ Assistance completing forms or reading written materials
☐Large-print materials
☐Braille Materials
☐Digital or screen-reader-friendly files (email or USB)
☐Sign language interpreter (ASL, SEE, or Other)
☐ Large screen
☐ Assistive listening device or captioning service
☐ Extended appointment time or flexible scheduling
☐ Service animal access
☐ Other (please describe):________________________________________________________
Patient Signature: ________________________________________ Date:_________________
Staff Signature: _________________________________________ Date: ________________
___ If patient is unable to sign due to disability, please select here and document patient’s verbal agreement along with a witness signature below.
Witness Signature: _______________________________ Date: ___________________
