PATIENT INFO & FORMS
Patient Forms
New Patients – Please complete and submit the following registration form before your appointment and the school release if you/your child is in school:
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:
School Release Form
Medical Release Form
Allergy Scratch Testing Information and Consent Form
Bravo Agreement Form– Please complete and submit this form at least 48 hours before your child’s procedure
PillCam™ Capsule Endoscopy Agreement Form – Please complete at least 24 hours before the test.
PillCam™ Capsule Endoscopy Consent
Dietitian New Patient Packet– Please click the link, print and complete packet, and bring it with you to your first appointment with the dietitian.
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:
Pelvic Floor Therapy– Please complete and submit the consent form below, then complete the questionnaire and you may email it to us via your portal or print it and bring it to your appointment.
HIPAA Privacy Policy–Please review
Insurance Waiver
Good Faith Estimate for Self-Pay Patients
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 form for any of our providers, locations, and/or specialty clinics.
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
