It is important that we, as your care providers, have available your complete medical history and other necessary contact information.

Below we have a list of commonly used forms and notices that our practice are required to complete or acknowledge.

If you are visiting our office for the first time, our staff can outline which forms you will be required to complete upon visitation and you may wish to download, complete and bring them with you to save time. These forms are here to help you get the care you need.

New Pediatric Patient Forms

Consent to Treat Form

This Consent to Treat Form gives a physician permission to treat your child

Pediatric Initial Health Assessment

New Adult Patient Forms

This form gives a physician important information to help during the consultation and offer the best preventive services

New Patient Forms Package

Health Risk Assessment

Patient Agreement

Activity Diet Assessment

Record Release


Business Hours

Dyersburg Clinic

Monday - Friday:
8 AM to 4:30 PM

Halls Clinic

Monday, Tuesday, Friday:
8 AM to 4:30 PM

Ripley Clinic

Monday - Friday:
8 AM to 4:30 PM