New Patient Forms
You may access the following forms to assist us with your care. Please print and complete the following forms, and bring them to your appointment.
New Patient Packet Form for all patients under the age of 18. A registration form is required each year to obtain current information for patients and parents.
New Patient Packet for ages 18 and more A registration form is required each year to obtain current information for patients.
Consent Forms & Financial Forms
You may access the following forms to assist us with your care. Please print and complete the following forms, and bring them to your appointment.
Consent to Treat Use for a one-time case where you will not be able to accompany your child to the office. A signed, faxed "Consent to Treat" form, sent by the parent with a valid phone number where the parent can be reached during the appointment. The parent MUST be available.
Consent to receive Medical Records: Authorization for release medical Records. Please complete this form to have your child's medical records released to our office, from your child's previous health care provider
Consent to release Medical Records: Authorization to receive medical records
Billing Guarantor Signoff: This form must be completed by the parent or guardian who will be present for office visits. It covers our financial responsibility policies and notice of privacy practices.
HIPPA Privacy Notice: If you are a new patient, we will ask you to read and sign a Privacy Notice. To save you time in the office, please read and sign this document. Bring only the signed last page with you to your appointment.
Acknowledgement of Financial Policy
Sports & Physicals forms
AIA Form: Sports clearance form accepted by most schools and teams. Please fill out the first 3 pages and bring the packet with you to your child's well visit. If your child already had a well visit within the past 12 month, please drop off the completed packet to the front desk and we will return the signed forms to you within 48-72 hours.
Behavioral & Development Forms
Behavioral Health Patient Intake form: Use this form for any new patient coming in for behavioral health evaluation
These Vanderbilt Parent & Teacher Rating Forms for ADD/ADHD may be requested as part of an evaluation for ADD/ADHD. Please complete and bring them with you to your child's appointment or fax to our office.
