PATIENT INFORMATION
MOTHER'S INFORMATION
FATHER'S INFORMATION
EMERGENCY
Please list the name of a relative or friend that does not live with you and can be contacted in case of an emergency
TENNCARE
TennCare MCO: Please present card
INSURANCE INFORMATION
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Please release a copy of all medical records, including but not limited to progress notes, operative notes, laboratory results, and diagnostic test.
BY MY SIGNATURE, I AUTHORIZE RELEASE OF MEDICAL RECORDS
After this date, the above individual will no longer be a patient of Cedar Creek Pediatric & Adolescent Medicine, P.C. All future medical treatment must be provided by your new doctor.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.