Tallahassee Disclosure of Ownership for CT Services

I hereby acknowledge that by signing this Consent, I acknowledge and agree to the following:

Please be advised that the following physicians own an interest in Advanced Urology Institute, whose address is listed below:

  • Robert S. Bradford, MD
  • David E. Burday, MD
  • James E. Renehan, MD
  • Jamey A. Sarvis, MD
  • Scott B. Sellinger, MD
  • Jean-Paul Tran, MD

I am entitled to obtain the CT services for which I have been referred at the location or from the provider or supplier of my choice, including Advanced Urology Institute.

Alternative sources of the items or services for CTs include:

  1. Tallahassee Memorial Hospital – 1300 Miccosukee Rd, Tallahassee, FL 32308 | Ph: 850-431-1155
  2. Capital Regional Medical Center – 2626 Capital Medical Blvd, Tallahassee, FL 32308 | Ph: 850-325-5000
  3. Radiology Associates – 1600 Phillips Rd, Tallahassee, FL 32308 | Ph: 850-878-4128
  4. Tallahassee Primary Care Associates – 1803 Miccosukee Commons Dr, Tallahassee, FL 32308 | Ph: 850-942-6624
  5. American Health Imaging – 2510 Miccosukee Rd, Unit 100, Tallahassee, FL 32308 | Ph: 850-942-1100