You may contact our office Monday through Friday from 8:00 a.m. to 4:15 p.m. at (865) 546-3998 to make an appointment.
Before your first office visit, please print and fill the new patient forms below. You only need to fill out New Patient Nutrition Packet if seeing the Registered Dietitian.
Patient Forms
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New Patients – Please complete and submit the following registration form before your appointment and the school release if you/your child is in school:
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Pacientes nuevos: Complete y envíe el siguiente formulario de registro antes de su cita y el permiso escolar si usted/su hijo está en la escuela:
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Medical Release
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Allergy Scratch Testing Information and Consent Form
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Bravo Agreement- Please complete and submit this form at least 48 hours before your child’s procedure:
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Dietitian New Patient Packet- Please print, complete, and bring this packet with you to your first appointment with the dietitian:
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Healthy Lifestyle Clinic- Please complete and submit the first two (2) forms and then print, complete, and bring the Questionnaire to your first appointment in the Healthy Lifestyle Clinic:
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HIPAA Privacy Policy-Please review
Provider Office Forms:
Submit your referral quickly online or download a fillable PDF version and fax to our office at 865-546-1123.
You can use either of these forms to submit a new patient referral for any of our providers, locations, and/or specialty clinics.
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Motility and Heartburn Clinic Referral Form- Please complete this form for specialty testing and fax to our office at 865-546-1123:
NOTE: Adobe Acrobat® reader is required to view and print some of these forms. If you do not already have Adobe Acrobat® reader installed, you can download it here.
Please Bring The Additional Following Items:
- Parent’s driver’s license
- Child’s insurance card
- Child’s social security number
- Any prescriptions that the child is taking in their original bottles
- **If you are a legal guardian, please bring appropriate documentation
For the first office visit we require a parent or legal guardian bring the child. For future appointments, another individual may bring the child as long as the parent has given written consent ahead of time. That individual is required to bring photo identification. This consent can be found at the bottom of the first page of the new patient forms.

1975 Town Center Blvd,
Knoxville, TN 37922
A Visit with a Registered Dietitian Nutritionist (RDN)
Administering a G-Tube Feeding using a Syringe
Administering a G-Tube Feeding using Gravity Feeding
Administering a Tube Feeding using a Feeding Pump
Alpha-1-Antitrypsin Deficiency
Bacterial Overgrowth Breath Test
Celiac Disease / Gluten Intolerance
Colazal (Balsalazide Disodium)
Colonoscopy Preparation (1 to 5 years of age)
Colonoscopy Preparation (10 to 18 years of age MOVIPREP)
Colonoscopy Preparation (10 to 18 years of age)
Colonoscopy Preparation (Children under 1 year of age)
Compliance problems with medical regimens
Congenital Sucrase-Isomaltase Deficiency (CSID)
Coping with Pain and Stress Related to Gall Bladder Disease
Cortenema (Hydrocortisone rectal)
Endoscopic Retrograde Cholangiopancreatography (ERCP)
Fecal Pancreatic Elastase Stool Testing
Gastrostomy Tube Placement and Changes
Healthy Eating Tips for Families
Ileoanal Reservoir (Pouch) Surgery
Inflammatory Bowel Disease and Diet
Lomotil (diphenoxylate hydrochloride and atropine sulfate tablets and solution)
Magnetic Resonance Cholangiopancreatography (MRCP)
GI For Kids – Cleveland, Tennessee
GI For Kids – Crossville, Tennessee
GI For Kids – Knoxville, Tennessee
GI For Kids – Morristown, Tennessee
Miralax (Polyethylene glycol 3350)
Nasogastric (NG) Tube Placement
Nexium (Esomeprazole Magnesium)
Nonalcoholic Fatty Liver Disease
Nutrition: Nonalcoholic Fatty Liver Disease
Phenergan (Promethazine Hydrochloride)
Polyps in the Gastrointestinal Tract
Prevpac – lansoprazole, amoxicillin and clarithromycin
Pulmicort (budesonide inhalation)
Pursuing Behavioral Health Services
Pylera (Metronidazole, Bismuth Subcitrate Potassium, and Tetracylcline Hydrocholoride)
Qvar (Beclomethasone) Oral Inhalation
Sacrosidase Oral Solution (Sucraid)*
Serum Infliximab/HACA Measurement
Total Parental Nutrition (TPN)
Zegerid (Omeprazole / Sodium Bicarbonate)
Zofran (Ondansetron Hydrochloride)

1975 Town Center Blvd,
Knoxville, TN 37922
A Visit with a Registered Dietitian Nutritionist (RDN)
Administering a G-Tube Feeding using a Syringe
Administering a G-Tube Feeding using Gravity Feeding
Administering a Tube Feeding using a Feeding Pump
Alpha-1-Antitrypsin Deficiency
Bacterial Overgrowth Breath Test
Celiac Disease / Gluten Intolerance
Colazal (Balsalazide Disodium)
Colonoscopy Preparation (1 to 5 years of age)
Colonoscopy Preparation (10 to 18 years of age MOVIPREP)
Colonoscopy Preparation (10 to 18 years of age)
Colonoscopy Preparation (Children under 1 year of age)
Compliance problems with medical regimens
Congenital Sucrase-Isomaltase Deficiency (CSID)
Coping with Pain and Stress Related to Gall Bladder Disease
Cortenema (Hydrocortisone rectal)
Endoscopic Retrograde Cholangiopancreatography (ERCP)
Fecal Pancreatic Elastase Stool Testing
Gastrostomy Tube Placement and Changes
Healthy Eating Tips for Families
Ileoanal Reservoir (Pouch) Surgery
Inflammatory Bowel Disease and Diet
Lomotil (diphenoxylate hydrochloride and atropine sulfate tablets and solution)
Magnetic Resonance Cholangiopancreatography (MRCP)
GI For Kids – Cleveland, Tennessee
GI For Kids – Crossville, Tennessee
GI For Kids – Knoxville, Tennessee
GI For Kids – Morristown, Tennessee
Miralax (Polyethylene glycol 3350)
Nasogastric (NG) Tube Placement
Nexium (Esomeprazole Magnesium)
Nonalcoholic Fatty Liver Disease
Nutrition: Nonalcoholic Fatty Liver Disease
Phenergan (Promethazine Hydrochloride)
Polyps in the Gastrointestinal Tract
Prevpac – lansoprazole, amoxicillin and clarithromycin
Pulmicort (budesonide inhalation)
Pursuing Behavioral Health Services
Pylera (Metronidazole, Bismuth Subcitrate Potassium, and Tetracylcline Hydrocholoride)
Qvar (Beclomethasone) Oral Inhalation
Sacrosidase Oral Solution (Sucraid)*
Serum Infliximab/HACA Measurement
Total Parental Nutrition (TPN)
Zegerid (Omeprazole / Sodium Bicarbonate)
Zofran (Ondansetron Hydrochloride)