PATIENT INFORMATION
MOTHER'S INFORMATION
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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.
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