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• ONLINE CHECK IN INFORMATION (PHREESIA/ECLINICALWORKS): Payment Card Information Security and Patient Health Information Security

For new patients, please download, print, and complete the following forms prior to your child's appointment.

Printable Forms

(Complete and bring to your next visit)

• Demographic Form 
• No Show Fee Agreement Form
• New Patient History Form
• Authorization to Release Medical Information to Family Members:
  (Patients 18-21 Years of Age)
• Health Information Exchange OPT-OUT Request Form

Medical Record Release Form

• Authorization for Health Information Disclosure
• Cost Information Sheet for Medical Records
• Medical Release Form Request (From Previous Medical Provider to Our Office)

Clinical Forms

• Maternal Post-Partum Depression Screening
• MCHAT-R Screening Form
• PEDS Form
• Teen Screen
• Refusal to vaccinate Form
• Preparticipation Physical Evaluation Form:  (Please complete first 2 pages before sending or dropping off)                                        (PLEASE ALLOW 48-72 HOURS FOR US TO COMPLETE AND RETURN TO YOU)
• Vanderbilt ADHD Parent Form
• Vanderbilt ADHD Teacher Form
• Anxiety Screening form (SCARED)
• PHQ9 - Depression Screen Form
• Oral Contraceptive Questionaire
• Prevaccination Checklist for COVID-19 Vaccines 

A $10 annual administration fee is charged per patient upon request of Sports/Camp/other Medical forms. 

THERE IS A 48-72 HOUR TURN AROUND TIME FOR ALL FORMS. THEY WILL BE UPLOADED TO THE PATIENT PORTAL FOR YOUR CONVENIENCE.

Secure Online Forms

• Forms 3231/3300 
  Please allow 48-72 hours for all form requests.
   
• Medical Records Request
   
• Online RX Refill Request