ALL PATIENT FORMS

Medical Records Release

• Please complete if you would like us to receive information from a previous medical provider.
  

HIPAA Acknowledgement

• Please complete this Notice of Privacy Practices/HIPAA Acknowledgement form to acknowledge your understanding of HIPAA privacy practices.
  

Family & Friends HIPAA Release

• Please complete if you would like to allow someone else to be able to discuss your care with your physician.
  

Emotional Health Screening Form

Your emotional health is as important as your physical health. If you have felt down, sad, or hopeless over the last 2 weeks or have felt little interest or pleasure in doing things, you may be depressed. Complete this form and then review with your doctor.

Kindergarten Health Assessment Form

This form must be completed prior to kindergarten entry. Please plan ahead and schedule a physical for your child after age four and prior to kindergarten entry.

Initial Vanderbilt Assessment Scale For Parents

Please print the parent and teacher assessment for completion and return to your provider's office once done.

Vanderbilt Teacher Assessment Scale

Please print the parent and teacher assessment for completion and return to your provider's office once done.

Follow-Up Vanderbilt Parent Assessment Scale

Please print the parent and teacher assessment for completion and return to your provider's office once done.

Follow-Up Vanderbilt Teacher Assessment Scale

Please print the parent and teacher assessment for completion and return to your provider's office once done.