Affidavit of Pain Clinic Physician

If you're opening or operating a pain management clinic in Miami-Dade County, appointing a Designated Physician is a legal requirement under county ordinances.

Download the official Affidavit of Designated Physician – a notarized legal form required for clinic registration and compliance with local law.

✅ Compliant with Miami-Dade Ordinance

✅ For Pain Management Clinics

✅ Includes Notary Section for Filing

🔍 What Is the Affidavit of Designated Physician?

This Affidavit of Designated Physician is a sworn statement completed by a physician who is designated to oversee and be accountable for a pain management clinic's operations. It is part of the mandatory registration process in Miami-Dade County and must be filed with the Consumer Protection Division.

📋 Key Requirements Outlined in This Form

• Physician is employed by or contracted with the named clinic

• Physician must have an active, unencumbered Florida medical license

• Must possess an active DEA registration

• Affirms no felony drug convictions or license revocations

• Commitment to notify the county if no longer affiliated with the clinic

• Includes full notarial acknowledgment section
  
  

🏥 Who Needs This Form?

• Owners or operators of pain management clinics in Miami-Dade County

• Designated physicians newly affiliated with a clinic

• Legal document preparers and compliance consultants in the medical field

• Physicians needing to maintain legal registration of clinic operations
  
  

📥 Get Your Affidavit of Designated Physician (PDF)

Our downloadable version is ready to complete, notarize, and submit to the county.

➡️ Click Here to Download the Affidavit (PDF)
(No email or login required)

✍️ Need Online Notarization?

We offer remote online notarization, as well as mobile notary services to help busy physicians and clinic owners finalize this document without needing to leave the office.

📫 Where to File This Form?

Contact the Miami-Dade County Consumer Protection Division for current filing procedures. This affidavit is typically submitted as part of the pain clinic registration or renewal packet.

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We can prepare, print, record and provide notarization of a number of forms.

Call: 1-877-540-6104 To Book A Mobile Notary for a Notarized Doc or other legal forms!