Forms
Before your first visit
The following forms are necessary prior to your initial visit. For your convenience, we have provided them here on our website so that you may have them ready at the time of your first visit.
Patient Information Sheet
Records_Release_from_Previous_Doctor
Notice of Privacy Practice
Important Information
The following forms are informational. The first describes our policy concerning patient forms and the second is an informational reminder to new parents about adding a new child to an insurance policy.
Form Policy Handout
Newborn Insurance Reminder for New Parents
Medical Records Policy
HIPAA 3rd Party Release
HIPAA Parent Release
Clinical Forms
Our providers may direct you to one or more of the following forms to aid in the diagnosis and/or treatment of various clinical situations.
M-CHAT
Teenage Mood Assessment
Vanderbilt parent (initial)
Vanderbilt teacher (initial)
Hydration
School Forms
Below is the State School Physical Form.
Flu Season Information
The following are forms concerning our flu season vaccination services. There are informational packets as well as consent forms for both types of vaccine.
Flumist Information
2011/2012 Flumist Waiver
2011-12 FluMist CDC VIS
Flushot CDC VIS 2011/2012
Flushot waiver 2011/2012
*As of January 1, 2009, we will start charging $5.00 to complete all school, college and camp forms for our patients. The charge will be for each form requested and payment will be collected before the form is completed. We require between 3-5 business days to complete the forms. You may then either pick them up at the office of your choice or provide us with a self addressed stamped envelope for mailing. You will need to complete a HIPAA release form if you want us to mail the form anywhere other than your home address. Please be aware that if the form has specific lab requirements or immunizations you need to make sure these have been met before we can even complete the form. A delay in obtaining lab work will of course increase the time frame to complete your forms.