New Patient Forms "*" indicates required fields 1Patient Demographics2Contact Information3Medical History4Consent to Treat5Additional Information Please complete this registration form in its entirety. Once submitted, you will receive a confirmation email including general practice information. If you have completed a paper copy of these forms, please click here. Acceptance into practice is based on geography. Registration is not proof of acceptance. Our office will reach out to you via email or phone to schedule your first appointment. If you have any special circumstances that you would like to bring to our attention, please let us know at the bottom of this registration.Personal InformationName* First Last Date of Birth* SSN* Type of Residence* Private Home Senior Living Community Home Visit Fee Consent*Private home patients are accepted based on geography and availability. All visits are billed a $200.00 home visit fee which is payable by patient at time of appointment. This fee is not billed to insurance. I agree to the above charges Community(Other)Abe’s GardenAzalea CourtBarton HouseBelmont VillageBelvedere CommonsBlakeford of Green HillsBridge at Hickory WoodsBrighton GardensBristol TerraceBrookdale at BellevueBrookdale of Belle MeadeBrookdale of FranklinBrookdale of HendersonvilleCadence Senior LivingCanterfield of FranklinCarrick GlennCharterClarendaleCreekside at Three RiversCrossings at Victory StationCumberland at GreenhillsCumberland View TowersDavid Jones, JrElmcroft of BrentwoodElmcroft of LebanonElmcroft of Lebanon (MC)Fountains of FranklinGardens of Providence PlaceHarmony of BrentwoodHearth of FranklinHearthside of LebanonHeritage of BrentwoodHickory HillsLong Hollow TerraceMain Street Senior LivingManor at SteeplechaseMaristone FranklinMaristone ProvidenceMary Queen of AngelsMcKendree VillageMorning Pointe of BrentwoodMorning Pointe of ColumbiaMorning Pointe of FranklinMorning Pointe of Spring HillMorningside of FranklinMorningside of SpringfieldNancy's PlaceNHC PlaceNorthpark VillageOak HillPark PlaceReserve at Spring HillRosecareRosecare the CottageRutland PlaceSaba SunriseSomerby of FranklinSouthern CareSouthern Manor LivingSouthernland PlaceSycamores TerraceThe VillagesTraditions of SmyrnaTraditions of Spring HillTrevecca TowersWaterford of HermitageWaterford of SmyrnaWillowsprings of Spring HillWindlands EastWindlands SouthApartment Number Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Personal PhoneCommunity PhoneEmail Required for access to patient portal.Gender* Male Female Marital Status Single Married Divorced Widowed Race White African American Hispanic American Indian Asian Other Primary Insurance* Insurance Member ID Secondary Insurance Insurance Member ID For a list of accepted insurances, please click here. Contact InformationPrimary Medical Contact*Please list who will be the primary person with whom we may discuss medical care. Self Other Primary Contact*Please provide the primary contact with whom we may discuss your care. First Middle Last Suffix Primary Contact Address* Street 1 Street 2 City State ZIP Additional Medical ContactsPlease provide any other individual with whom we may discuss your care.NamePhoneEmailRelationship Add RemoveBilling Information*Where will invoices and insurance related information be mailed? Self Primary Medical Contact Other Billing Address* Street Address Address Line 2 City EmailAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Medical InformationMedication List*Please provide a complete list of all current medications.NameStrengthDirection Add RemovePharmacy Name Phone Allergies Add RemoveImmunizationsPlease provide immunization history.VaccineDate Add RemoveMedical History CVA / Stroke Dementia Hearing Loss Cataracts Atrial Fibrillation Heart Failure Coronary Artery Disease Hypertension Heart Attack COPD / Emphysema Hyperlipidemia Diabetes Diverticulitis Arthritis Anemia Cancer Family HistoryFatherMotherChild Add RemoveSurgical HistorySurgeryDate Add RemoveHospitalizationHave you been hospitalized in the last 90 days? Yes No I Don't Know HospitalizationPlease describe the nature of your hospital visit, such as where you were admitted, why, and when you discharged?Smoking Status* Never Smoker Former Smoker Current Smoker How long ago did you quit? This year Less than 5 years ago More than 5 years ago Are you interested in quitting? Yes No Alcohol Use* Current Drinker Former Drinker Never Drinker How often do you drink? Once a day Few times a week Few times a month Advance DirectivesPlease list all advance directives you wish us to respect. Do Not Resuscitate Full Code Power of Attorney Copy of Advanced DirectivePlease upload a copy of your Advanced Directive. Drop files here or Select files Accepted file types: pdf, Max. file size: 256 MB. Consent to TreatConsent* I agree to the terms and conditions of service.Medical Consent HIPAA NoticeCare Management Services*Do you wish to have a Care Manager oversee you or your loved one's care? Care Managers provide enhanced communication, timely fulfillment of prescriptions, scheduling of referrals and more. Their goal is to reduce ER visits and hospitalization, expedite coordination of care, and provide a point of contact for all healthcare needs. Yes No CCM ConsentSignature* Special RequestsCAPTCHA