Forms

Patient Registration Form– New as of 4/23/19. This form is required for every established patient to do once after this date, and for any new patients.  First 2 pages is contact information for the household, and 3rd page is patient medical history.  Spanish

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.

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

SCHOOL FORMS:

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

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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