Forms

 

Letter regarding new policies (New 6/8/17)

Authorization to treat (New 6/8/17) – consent is required to see a child who is accompanied by someone other than a parent or legal guardian. No exceptions after 11/1/2017.

 

New Patient Form

Authorization to release personal health information – to send or receive records

Sports Physical– please complete the front page prior to your appointment

Kindergarten Physical – please complete the parent section at the top of page 1.

Wilson Co. Schools Medication Administration Form

ADHD evaluation forms (Vanderbilt Assessments) – Your doctor may request that you and your child’s teachers complete these forms to help diagnose ADHD. One parent needs to complete the PARENT form, and atleast 2 teachers need to complete the TEACHER form (choose teachers that have spent the most time with your child).  These forms should be dropped off or faxed in prior to your child’s appointment as they take time to be reviewed and scored.

 

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