PATIENT INFO & FORMS
Patient Forms
New Patients
Please complete and submit the following forms linked below before the first appointment.
Other Forms and Information
Medical Release Form
HIPAA Privacy Policy–Please review
Insurance Waiver
Good Faith Estimate for Self-Pay Patients
Self-Pay Rates
Provider Office Forms:
Submit your referral online or download a fillable PDF version and fax to our office at 865-546-1123.
New Patient Referral Form- Fillable PDF
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 Following Items to your appointment:
- 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
